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When an individuals stress response is sustained over a long period of time, which physiological effect of the endocrine system should a nurse anticipate?
- A. Decreased resistance to disease
- B. Increased libido
- C. Decreased blood pressure
- D. Increased inflammatory response
Correct Answer: A
Rationale: The correct answer is A: Decreased resistance to disease. Prolonged stress can weaken the immune system, making individuals more susceptible to illnesses. Chronic stress suppresses immune functions, leading to decreased resistance to diseases. The other choices are incorrect because increased libido (B) and decreased blood pressure (C) are not typical physiological effects of sustained stress. While stress can lead to increased inflammatory response (D), the primary concern with chronic stress is its negative impact on the immune system, making choice A the most appropriate answer in this context.
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A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions?
- A. I will need scheduled bloodwork in order to monitor for toxic levels of this drug.
- B. I wont stop taking this medication abruptly, because there could be serious complications.
- C. I will not drink alcohol while taking this medication.
- D. I wont take extra doses of this drug because I can become addicted.
Correct Answer: A
Rationale: The correct answer is A because the statement indicates a misunderstanding. Benzodiazepines do not require routine blood monitoring for toxicity. Benzodiazepines are typically monitored based on clinical response and potential side effects. Choices B, C, and D are all correct statements related to benzodiazepine use, emphasizing the importance of not abruptly stopping the medication, avoiding alcohol, and not taking extra doses to prevent addiction.
A nurse understands that the abnormal secretion of growth hormone may play a role in which illness?
- A. Schizophrenia
- B. Anorexia nervosa
- C. Alzheimers disease
Correct Answer: B
Rationale: The correct answer is B: Anorexia nervosa. Growth hormone abnormalities can contribute to the development of anorexia nervosa by affecting metabolism and body composition. Increased levels of growth hormone can lead to muscle wasting and weight loss, which are common symptoms of anorexia nervosa. In contrast, schizophrenia is primarily associated with neurotransmitter imbalances, Alzheimer's disease is linked to neurodegeneration, and diabetes is often related to insulin abnormalities.
An unemployed college graduate is experiencing severe anxiety over not finding a teaching position and has difficulty with independent problem-solving. During a routine physical examination, the graduate confides in the clinic nurse. Which is the most appropriate nursing intervention?
- A. Encourage the student to use the alternative coping mechanism of relaxation exercises.
- B. Complete the problem-solving process for the client.
- C. Work through the problem-solving process with the client.
- D. Encourage the client to keep a journal.
Correct Answer: C
Rationale: The correct answer is C: Work through the problem-solving process with the client. This option promotes empowerment and autonomy by guiding the client to develop their problem-solving skills. It allows the nurse to offer support and guidance without taking over the process entirely, fostering independence and self-efficacy. Encouraging the client to actively participate in finding solutions can help build confidence and improve their ability to handle similar situations in the future.
Explanation for other choices:
A: Encouraging relaxation exercises can be helpful for managing anxiety, but it does not directly address the underlying issue of developing problem-solving skills.
B: Completing the problem-solving process for the client does not empower the client to learn how to address similar challenges independently.
D: Keeping a journal can be a helpful tool for self-reflection and managing emotions, but it does not specifically address the client's difficulty with independent problem-solving.
In the situation presented, which nursing intervention constitutes false imprisonment?
- A. The client is combative and will not redirect, stating, No one can stop me from leaving. The nurse seeks the physicians order after the client is restrained.
- B. The client has been consistently seeking the attention of the nurses much of the day. The nurse institutes seclusion.
- C. A psychotic client, admitted in an involuntary status, runs off the psychiatric unit. The nurse runs after the client and the client agrees to return.
- D. A client hospitalized as an involuntary admission attempts to leave the unit. The nurse calls the security team and they prevent the client from leaving.
Correct Answer: A
Rationale: The correct answer is A because false imprisonment occurs when a person is unlawfully restrained. In this scenario, the client is restrained without a physician's order, which is considered unlawful. Seeking a physician's order after the client is already restrained does not justify the action.
Choice B is incorrect because seclusion is a valid nursing intervention for managing disruptive behavior, as long as it is done in a safe and ethical manner.
Choice C is incorrect because the nurse's actions of running after the client and convincing them to return do not constitute false imprisonment.
Choice D is incorrect because preventing a client hospitalized as an involuntary admission from leaving with the help of security is a valid intervention to ensure the safety of the client and others.
Which client statement may indicate a transference reaction?
- A. I need a real nurse. You are young enough to be my daughter and I dont want to tell you about my personal life.
- B. I deserve more than I am getting here. Do you know who I am and what I do? Let me talk to your supervisor.
- C. I dont seem to be able to relate to people. I would rather stay in my room and be by myself.
- D. My mother is the source of my problems. She has always told me what to do and what to say.
Correct Answer: A
Rationale: Step 1: The client's statement "I need a real nurse" suggests a desire for a particular type of nurse, implying a transfer of feelings from a significant person onto the nurse.
Step 2: The client mentioning the nurse's age and relationship dynamics ("young enough to be my daughter") indicates projection of unresolved emotions onto the nurse.
Step 3: The client's reluctance to share personal information and discomfort with the nurse's perceived identity further supports the presence of transference reactions.
Summary: Option A is correct as it demonstrates transference by projecting emotions onto the nurse based on age and personal dynamics. Other choices lack clear indications of transference and focus on different issues like entitlement, social interaction difficulties, and blaming family members.