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When the caregiver of a child asks the nurse for reassurance about their child's condition, which of the following responses should the nurse make?
- A. "I think your child is getting better. What have you noticed?"
- B. "I'm sure everything will be okay. It just takes time to heal."
- C. "I'm not sure what's wrong. Have you asked the doctor about your concerns?"
- D. "I understand you're concerned. Let's discuss what concerns you specifically."
Correct Answer: D
Rationale: When providing reassurance to a caregiver about their child's condition, it's essential to acknowledge their concern and address it specifically. Response D demonstrates empathy and a willingness to discuss the caregiver's specific concerns, which can help in providing accurate information and support to them. Choices A and B provide general reassurance without addressing the caregiver's specific concerns, which may not alleviate their worries effectively. Choice C deflects the question back to the caregiver and suggests consulting the doctor without directly engaging with the caregiver's worries, which may not offer the needed support and reassurance.
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Child protective services have removed 10-year-old Christopher from his parents' home due to neglect. Christopher reveals to the nurse that he considers the woman next door his 'nice' mom, that he loves school, and gets above-average grades. The strongest explanation for this response is:
- A. Temperament
- B. Genetic factors
- C. Resilience
- D. Paradoxical effects of neglect
Correct Answer: C
Rationale: Resilience is the ability to adapt positively in the face of adversity. Christopher's positive outlook and academic success despite experiencing neglect demonstrate his resilience in coping with challenging circumstances. Choice A, Temperament, refers to inherent traits and is not the most fitting explanation for Christopher's response. Genetic factors (Choice B) play a role in development but do not directly explain Christopher's ability to cope. The paradoxical effects of neglect (Choice D) typically refer to unexpected positive outcomes, which do not fully capture Christopher's situation.
A client is undergoing systematic desensitization for an extreme fear of elevators. Which of the following actions should be implemented with this form of therapy?
- A. Demonstrate riding in an elevator, then ask the client to imitate the behavior.
- B. Advise the client to say "stop" out loud every time they begin to feel an anxiety response related to an elevator.
- C. Gradually expose the client to an elevator while practicing relaxation techniques.
- D. Stay with the client in an elevator until the anxiety response diminishes.
Correct Answer: C
Rationale: Systematic desensitization is a type of therapy used to help individuals overcome phobias or anxieties. It involves gradually exposing the client to the feared object or situation, in this case, an elevator, while simultaneously practicing relaxation techniques. This process helps the client associate relaxation with the previously feared stimulus, gradually reducing anxiety levels over time. Choice A is incorrect as it involves imitation rather than gradual exposure. Choice B is incorrect as it focuses on a verbal response rather than the systematic process of exposure and relaxation. Choice D is incorrect as it does not involve the systematic approach of gradually exposing the client while teaching relaxation techniques.
A healthcare professional is caring for a group of clients. Which of the following clients should the healthcare professional consider for referral to an assertive community treatment (ACT) group?
- A. A client in an acute care mental health facility who has fallen several times while running down the hallway
- B. A client who lives at home and keeps forgetting to come in for a scheduled monthly antipsychotic injection for schizophrenia
- C. A client in a day treatment program who reports increasing anxiety during group therapy
- D. A client in a weekly grief support group who reports still missing a deceased partner who has been dead for 3 months
Correct Answer: B
Rationale: The client who lives at home and repeatedly forgets to come in for a scheduled monthly antipsychotic injection for schizophrenia should be considered for referral to an assertive community treatment (ACT) group. ACT teams provide intensive community-based treatment and support for individuals with severe mental illness who may have difficulty adhering to treatment on their own. Choices A, C, and D do not describe individuals with severe mental illness who have difficulty adhering to treatment or need intensive community-based support, which are the typical candidates for referral to an ACT group.
A community mental health nurse is planning care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse implement as a method of tertiary prevention?
- A. Educating clients on health promotion techniques to reduce the risk of depression
- B. Performing screenings for depression at community health programs
- C. Establishing rehabilitation programs to decrease the effects of depression
- D. Providing support groups for clients at risk for depression
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse is planning care for several clients attending community-based mental health programs. Which of the following clients should the nurse visit first?
- A. A client who received a burn on the arm while using a hot iron at home
- B. A client who requests a change of antipsychotic medication due to new adverse effects
- C. A client who reports hearing a voice saying that life is not worth living anymore
- D. A client who tells the nurse about experiencing manifestations of severe anxiety before and during a job interview
Correct Answer: C
Rationale: The nurse should visit the client who reports hearing a voice saying that life is not worth living anymore first. This statement indicates potential suicidal ideation, which requires immediate intervention to ensure the client's safety. Choices A, B, and D do not present an immediate threat to the client's life. While burns, adverse effects of medication, and severe anxiety are important concerns, they do not pose an immediate risk of self-harm or suicide.