Nokea
Which initial reaction would the nurse expect if the client is typical of others who just received news of this diagnosis?
- A. Anger
- B. Shock
- C. Resentment
- D. Depression
Correct Answer: B
Rationale: Shock is the most common initial reaction to an HIV diagnosis, as it reflects the overwhelming and unexpected nature of the news.
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Which response by the nurse is best in this situation?
- A. That is something to discuss with your physician.
- B. It sounds like you're feeling discouraged.
- C. But you're about your lack of progress.
- D. You need to practice a little more patience.
Correct Answer: B
Rationale: Acknowledging discouragement validates the client's feelings, fostering therapeutic communication and emotional support.
When debriefing the unit’s staff after the client’s catastrophic reaction the nurse stresses the need for the staff to remain calm during the event. Which statement should be the basis for the nurse’s comment?
- A. The client’s safety is at jeopardy if the staff is feeling threatened.
- B. An agitated staff will not be able to manage the situation as effectively.
- C. The client will sense the staff’s agitation and aggressive behavior will escalate.
- D. An agitated staff response is indicative of a need for additional crisis-control training.
Correct Answer: C
Rationale: Staff agitation escalates client aggression (C). Safety (A) management (B) and training (D) are secondary concerns.
The nurse correctly informs the caller that most people have which physical signs after recent marijuana use? Select all that apply.
- A. Shivering
- B. Inflamed eyes
- C. Rapid pulse
- D. Restlessness
- E. Pinpoint pupils
- F. Increased sex drive
Correct Answer: B,C,D
Rationale: Recent marijuana use commonly causes inflamed (red) eyes due to vasodilation, rapid pulse from cardiovascular stimulation, and restlessness from its psychoactive effects.
The client receiving treatment for substance dependence has not been attending group therapy. Which response by the nurse to confront this behavior is best?
- A. “Why don’t you want to go to group therapy? Other users are there waiting for you to attend.”
- B. “Talking about personal issues with others can be difficult. Try talking to the therapist alone.”
- C. “Therapy is important to your treatment. You need to attend therapy if you want to get better.”
- D. “You say you want to get better but you are not actively participating in your treatment plan.”
Correct Answer: D
Rationale: Confronting nonattendance nonjudgmentally (D) addresses denial. “Why” questions (A) suggesting alternatives (B) or threats (C) are less effective.
The new nurse is working with the cognitively impaired client who has a history of violent behavior. Which statement made by the new nurse reflects an immediate need for follow-up by the mentor?
- A. “My first concern is the safety of all those on the unit.”
- B. “I know to turn off the television when the client starts pacing the floor.”
- C. “When the client started getting aggressive I tried talking the client down.”
- D. “I’m going to try and assign the same staff to work with the client each shift.”
Correct Answer: C
Rationale: Talking during aggression (C) adds stimuli and requires mentor follow-up. Safety focus (A) reducing stimuli (B) and consistent staff (D) are appropriate.