Nokea
Which intervention should a nurse prioritize when caring for a client with alcohol use disorder?
- A. Helping the client identify positive personality traits
- B. Providing adequate hydration and rest
- C. Confronting denial and defense mechanisms
- D. Educating the client about alcohol misuse
Correct Answer: B
Rationale: The correct answer is B: Providing adequate hydration and rest. This intervention is crucial because individuals with alcohol use disorder often experience dehydration and fatigue due to excessive alcohol consumption. Hydration helps to flush out toxins and restore electrolyte balance, while rest supports physical and mental recovery. Helping the client identify positive personality traits (A) may be beneficial in building self-esteem but is not as urgent as addressing physical needs. Confronting denial and defense mechanisms (C) may lead to resistance and hinder the therapeutic relationship. Educating the client about alcohol misuse (D) is important but should be done after addressing immediate physical needs.
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A nurse is caring for an older adult client who had a cerebrovascular accident and has right-sided paralysis and aphasia. The client's son tells the nurse it is his fault because he did not insist that his mother live with him. Which of the following responses should the nurse make?
- A. "So, it seems that you feel responsible for what happened to your mother."
- B. "Your mother will be fine. You shouldn't worry so much."
- C. "Why do you blame yourself? You could not have prevented the stroke."
- D. "You are not responsible for your mother's stroke, but many people in your situation feel this way."
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
A is the correct response because it acknowledges the son's feelings without dismissing or invalidating them. It shows empathy and understanding towards his guilt, opening up a conversation for further exploration of his emotions. It reflects active listening and validates his concerns.
Summary of Incorrect Choices:
B: This response minimizes the son's feelings and does not address his sense of guilt, which can further exacerbate his emotional distress.
C: While this response provides reassurance, it does not address the son's feelings of guilt and may come off as dismissive.
D: This response acknowledges the son's feelings but does not directly validate his sense of responsibility, missing an opportunity for therapeutic communication.
A nurse is caring for a client whose partner is requesting to bring the client food from home that is not allowed in the client's dietary plan. Which of the following responses should the nurse make?
- A. "Why would you want to put your partner's health at further risk?"
- B. "You will need to discuss your concerns about your partner's diet with the provider."
- C. "Everyone likes food from home, but it can delay your partner's recovery."
- D. "Let's try to find ways to incorporate your partner's favorite food into her diet plan."
Correct Answer: D
Rationale: The correct answer is D: "Let's try to find ways to incorporate your partner's favorite food into her diet plan." This response acknowledges the partner's desire to bring food from home while also emphasizing the importance of adhering to the client's dietary plan for recovery. By suggesting a compromise to incorporate the favorite food within the diet plan, the nurse is promoting collaboration and patient-centered care. It shows understanding and empathy towards the partner's concerns while prioritizing the client's health and recovery.
Choice A is incorrect as it may come off as judgmental and dismissive. Choice B is not the most appropriate response as it doesn't address the partner's request directly. Choice C is incorrect as it may sound like a blanket statement and could potentially create tension between the nurse and the partner.
A nurse is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse identify as the primary cause of liver cirrhosis?
- A. Alcohol
- B. Caffeine
- C. Cocaine
- D. Inhalants
Correct Answer: A
Rationale: Chronic alcohol use is the leading cause of liver cirrhosis due to its toxic effects on liver cells.
A nurse is assessing a child who has autism spectrum disorder. Which of the following findings should the nurse expect?
- A. Delayed language development
- B. Spinning a toy repetitively
- C. Ritualistic behavior
- D. Consistent limit testing
Correct Answer: A, B, C
Rationale: Delayed language skills, repetitive behaviors, and a need for routines are common in autism spectrum disorder.
A nurse is caring for a client who has a history of alcohol use disorder and has been hospitalized for detoxification. The nurse enters the room and finds the client shouting in a terrified voice, "Get these bugs off of me!” Which of the following responses by the nurse is appropriate?
- A. "I'm sure that the bugs you see will not harm you."
- B. "Tell me more about the bugs that you see in your room."
- C. "I don't see any bugs, but you seem very frightened."
- D. "I do not see anything. This is part of the withdrawal process."
Correct Answer: C
Rationale: Response C is appropriate because it acknowledges the client's feelings without confirming the presence of bugs. This response shows empathy and understanding while not reinforcing the client's hallucination. Response A dismisses the client's fear and may increase anxiety. Response B encourages the client to focus on the hallucination, worsening the distress. Response D invalidates the client's experience and may lead to distrust.