Nokea
When one older adult at reminiscence therapy says, 'If I had it to do all over again, I wouldn't change a thing,' the nurse is most accurate in interpreting this to mean that the client has acquired which developmental characteristic?
- A. Trust
- B. Integrity
- C. Intimacy
- D. Autonomy
Correct Answer: B
Rationale: Accepting one's life without regret reflects integrity, per Erikson's stage of integrity vs. despair in late adulthood.
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The nurse is planning care for the client who has a cognitive deficit and a history of violence following head trauma. What is the primary effect of a cognitive deficit that can contribute to the client having a catastrophically violent reaction?
- A. The client’s ability to process information including instructions is limited.
- B. The client has a decreased ability to interpret and tolerate sensory stimuli.
- C. The staff has a more difficult time providing appropriate milieu boundaries.
- D. The staff’s attention is oftentimes diverted to other more manipulative clients.
Correct Answer: B
Rationale: Decreased ability to tolerate sensory stimuli (B) triggers catastrophic reactions. Processing (A) boundaries (C) and staff attention (D) are not primary contributors.
The nurse is conducting an admission history on the client being hospitalized with symptoms characteristic of schizophrenia. Which interview question demonstrates that the nurse can identify the most prevalent comorbid substance abuse issue for the client with schizophrenia?
- A. “When did you last smoke or use marijuana?”
- B. “Did you bring any street drugs to the hospital?”
- C. “How much alcohol do you drink in a 24-hour period?”
- D. “Did you give the nursing assistant all your cigarettes and lighters?”
Correct Answer: D
Rationale: Nicotine use (D) is most prevalent (70-90%) in schizophrenia. Marijuana (A) street drugs (B) and alcohol (C) are less common.
If a schizophrenic client says, 'Wing ding, the world is a ring,' which response by the nurse is most therapeutic?
- A. How clever. You've made up a poem.
- B. I don't understand what you mean.
- C. Let's talk about what's happening today.
- D. Tell me more about what you're thinking.
Correct Answer: B
Rationale: Acknowledging the nurse's lack of understanding gently prompts clarification, fostering communication without reinforcing delusional content.
The client is hospitalized after sustaining a head injury and a fractured wrist from a fall. The client admits to drinking alcohol in moderation several times per week. Which assessment finding should the nurse associate with early alcohol withdrawal?
- A. Agitation
- B. Somnolence
- C. Slightly elevated BP
- D. Delirium tremens (DTs)
Correct Answer: C
Rationale: Slight BP elevation (C) is an early withdrawal sign. Agitation and DTs (A D) occur later somnolence (B) is unrelated.
When the depressed client is scheduled for a series of electroconvulsive therapy (ECT) treatments, which reaction is most likely to be manifested in the immediate recovery period?
- A. A brief period of absence seizures
- B. Sensitivity to light and double vision
- C. Short-term memory loss and headaches
- D. Periods of unexplained fear and anxiety
Correct Answer: C
Rationale: Short-term memory loss and headaches are common post-ECT effects due to temporary brain disruption.