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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 client has made the decision to leave her alcoholic husband. She is feeling very depressed. Which nontherapeutic statement by the nurse conveys sympathy?
- A. You are feeling very depressed. I felt the same way when I decided to leave my husband.
- B. I can understand you are feeling depressed. It was a difficult decision. Ill sit with you.
- C. You seem depressed. It was a difficult decision to make. Would you like to talk about it?
- D. I know this is a difficult time for you. Would you like a prn medication for anxiety?
Correct Answer: A
Rationale: The correct answer is A because it shows empathy by sharing a personal experience to connect with the client emotionally. It validates the client's feelings and normalizes them. Choice B doesn't convey personal experience, and choice C lacks the personal touch. Choice D offers medication instead of emotional support, which is not therapeutic in this situation.
A nurse is interviewing a distressed client, who relates being fired after 15 years of loyal employment. Which of the following questions would best assist the nurse to determine the clients appraisal of the situation? Select all that apply.
- A. What resources have you used previously in stressful situations?
- B. Have you ever experienced a similar stressful situation?
- C. Who do you think is to blame for this situation?
- D. Why do you think you were fired from your job?
Correct Answer: A
Rationale: The correct answer is A: "What resources have you used previously in stressful situations?" This question is the best choice as it focuses on understanding the client's coping mechanisms and resilience. By asking about previous resources used, the nurse can assess the client's strengths and support systems.
Choice B is incorrect because asking if the client has experienced a similar situation does not directly address the client's current appraisal of the situation.
Choice C is incorrect as it focuses on assigning blame, which may not be helpful in understanding the client's perspective and emotions.
Choice D is also incorrect because asking why the client thinks they were fired may lead to a defensive response and may not necessarily provide insight into the client's appraisal of the situation.
According to Eriksons developmental theory, when planning care for a 47-year-old client, which developmental task should a nurse identify as appropriate for this client?
- A. To achieve a sense of self-confidence and recognition from others
- B. To reflect back on life events to derive pleasure and meaning
- C. To achieve established life goals and consider the welfare of future generations
Correct Answer: B
Rationale: In Erikson's theory, the developmental task for a 47-year-old client aligns with the stage of Generativity vs. Stagnation. Choice B, reflecting on life events for pleasure and meaning, corresponds to this stage where individuals assess their accomplishments and seek fulfillment. This phase involves contributing to society and future generations. Choice A pertains to the earlier stage of Identity vs. Role Confusion in adolescence. Choice C aligns with the later stage of Integrity vs. Despair in older adulthood. Choice D is incomplete. Therefore, the correct answer is B as it best fits the age and developmental stage of the client in question.
What is the priority nursing action during the orientation (introductory) phase of the nurseclient relationship?
- A. Acknowledge the clients actions and generate alternative behaviors.
- B. Establish rapport and develop treatment goals.
- C. Attempt to find alternative placement.
- D. Explore how thoughts and feelings about this client may adversely impact care.
Correct Answer: B
Rationale: The correct answer is B: Establish rapport and develop treatment goals. During the introductory phase of the nurse-client relationship, establishing rapport is essential to build trust and a therapeutic alliance. Developing treatment goals collaboratively with the client sets the foundation for the care plan. This action promotes client engagement and empowerment. Acknowledging client actions and generating alternative behaviors (A) is more suited for later phases. Attempting to find alternative placement (C) is not appropriate in the introductory phase. Exploring how thoughts and feelings impact care (D) is important but not the priority during the orientation phase.
A client is taking chlordiazepoxide (Librium) for generalized anxiety disorder symptoms. In which situation should a nurse recognize that this client is at greatest risk for drug overdose?
- A. When the client has a knowledge deficit related to the effects of the drug
- B. When the client combines the drug with alcohol
- C. When the client takes the drug on an empty stomach
- D. When the client fails to follow dietary restrictions
Correct Answer: B
Rationale: The correct answer is B: When the client combines the drug with alcohol. Combining chlordiazepoxide with alcohol can potentiate the central nervous system depression effects, leading to respiratory depression, sedation, and potential overdose. Alcohol can enhance the sedative effects of chlordiazepoxide, increasing the risk of overdose. A, C, and D are incorrect because a knowledge deficit, taking the drug on an empty stomach, or failing to follow dietary restrictions are not directly related to increasing the risk of drug overdose in this specific scenario.