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Which finding in the client's history strongly suggests lack of achieving the characteristic developmental level expected at this age in the life cycle?
- A. The client drifts in and out of relationships.
- B. The client worries about financial security.
- C. The client questions personal sexual identity.
- D. The client hesitates to be assertive.
Correct Answer: A
Rationale: Drifting in and out of relationships indicates difficulty achieving intimacy, a key developmental task of young adulthood per Erikson's stages.
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When providing care for an Asian client diagnosed with mental illness, which barriers should be considered before the treatment? Select all that apply.
- A. Language
- B. Literacy
- C. Somatization of mental health symptoms
- D. Food preferences
- E. Client's tendency to give limited information
- F. Financial status
Correct Answer: A,C,E
Rationale: Language barriers, somatization, and limited disclosure are common cultural factors in Asian clients, impacting mental health treatment access.
The nurse is developing the plan of care for the client diagnosed with schizophrenia who is having an alcohol-induced crisis. Which specific client outcome best reflects the primary goal of crisis intervention for this client?
- A. Client will be successfully detoxified within 20 days.
- B. Client will return to his or her part-time job within 20 days.
- C. Client will state two effective coping mechanisms prior to discharge.
- D. Client will demonstrate self-administration of medications prior to discharge.
Correct Answer: B
Rationale: Returning to pre-crisis functioning like work (B) is the crisis intervention goal. Detox (A) stating coping mechanisms (C) and medication administration (D) are secondary.
When the nurse responds to a call from a 22-year-old rape victim, which instruction is most important before referring the client to the emergency department of the local hospital?
- A. Do not bathe or shower.
- B. Make a sketch of the rapist.
- C. Write down what happened.
- D. Call a 911 operator.
Correct Answer: A
Rationale: Advising the victim not to bathe preserves forensic evidence, which is critical for potential criminal investigation and prosecution.
The nurse manager concerned about the potential for staff harm on a behavioral health unit is assessing the unit’s milieu. Which milieu situation should the nurse manager address because it is a predictive factor for violence?
- A. Two clients have a history of spousal abuse.
- B. Several clients have lost smoking privileges.
- C. The unit is currently at less than full client capacity.
- D. The nurse from a medical unit is assigned to work on the unit.
Correct Answer: D
Rationale: Staff inexperience (D) predicts violence. Client history (A) and privileges (B) are client-focused and low capacity (C) reduces not increases risk.
Which assessment finding is most atypical of a 65-year-old client?
- A. Making errors in copying a line drawing
- B. Forgetting the names of longstanding neighbors
- C. Reading information slowly
- D. Naming only two of the last three presidents
Correct Answer: A
Rationale: Errors in copying a drawing suggest visuospatial deficits, less common in typical aging and more indicative of neurological issues.