Nokea
Which of the following attitudes is essential in a nurse who assists clients during crises?
- A. viewing crisis intervention as the first step in solving bigger problems
- B. wanting to help clients solve all problems identified
- C. taking an active role in guiding the process
- D. feeling that work requires identification with all of a client's problems
Correct Answer: A
Rationale: Viewing crisis intervention as the first step in solving bigger problems is essential in a nurse who assists clients during crises. This approach focuses on addressing the immediate crisis first, which can potentially prevent the escalation of bigger problems. Wanting to help clients solve all problems identified (Choice B) may not be feasible or necessary during a crisis situation where immediate intervention is crucial. Taking an active role in guiding the process (Choice C) is important, but the primary focus should be on crisis intervention. Feeling that work requires identification with all of a client's problems (Choice D) may lead to a lack of focus on the immediate crisis at hand.
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Referral for client education in the community can be accomplished through all of the following except:
- A. community agencies such as the American Heart Association
- B. parish nurses
- C. home health care agencies
- D. unlicensed massage therapists
Correct Answer: D
Rationale: Client education should be conducted by individuals with acknowledged expertise in the subject area and appropriate credentials to support their activities within the healthcare community. Choices A, B, and C involve reputable entities or professionals who can provide accurate and reliable client education. The American Heart Association, parish nurses, and home health care agencies are recognized for their healthcare-related knowledge and qualifications. However, unlicensed massage therapists lack the necessary qualifications and expertise to deliver appropriate healthcare-related education, making them unsuitable for referrals when it comes to client education in the community.
When working with a client diagnosed with Borderline Personality Disorder who frequently attempts self-harm, what is the best intervention to facilitate behavior change?
- A. Constantly observing the client to prevent self-harm.
- B. Enlisting the client in defining and describing harmful behaviors.
- C. Checking on the client every 15 minutes to ensure they are not engaging in harmful behavior.
- D. Removing all items from the environment that the client could use to harm themselves.
Correct Answer: B
Rationale: The most effective intervention when working with clients who have a history of self-harm, like the client diagnosed with Borderline Personality Disorder, is to involve them actively in their treatment. By enlisting the client to define and describe the harmful behaviors, the client becomes an integral part of identifying triggers and understanding the underlying causes of their actions. This approach empowers the client, promotes self-awareness, and fosters a sense of control over their behaviors. Constantly observing the client (Choice A) may lead to a lack of trust and hinder the therapeutic relationship. Checking on the client every 15 minutes (Choice C) may disrupt the client's sense of autonomy and privacy. Removing all items from the environment that could be used for self-harm (Choice D) is a temporary solution and does not address the root causes of the behavior.
A healthcare provider is preparing to assess the acoustic nerve during a neurological examination. To assess this nerve, the provider uses which technique?
- A. Uses a tuning fork
- B. Asks the client to puff out the cheeks
- C. Tests taste perception on the client's tongue
- D. Checks the client's ability to clench the teeth
Correct Answer: A
Rationale: Testing of cranial nerve VIII (acoustic nerve) involves assessing hearing acuity through techniques like the whispered voice test and tuning fork tests (Weber and Rinne). Using a tuning fork helps determine if sound lateralizes to one ear (Weber) and compares air conduction to bone conduction (Rinne). Asking the client to puff out the cheeks is for cranial nerve VII (facial nerve) function evaluation. Testing taste perception on the tongue assesses cranial nerve IX (glossopharyngeal nerve) function. Checking the ability to clench teeth assesses cranial nerve V (trigeminal nerve) motor function.
An adolescent female reports being raped at a party where alcohol was served. The client admits to drinking alcohol before being raped by an acquaintance. The nurse should:
- A. inform the client that because she is underage, she is not at fault for attending a party where alcohol was served.
- B. ask the client if anyone witnessed the event because the client was intoxicated and might not remember it accurately.
- C. inform the client that it was not her fault, and support the client through the physical examination.
- D. question whether the woman had consensual sex and now just feels guilty.
Correct Answer: C
Rationale: In cases of rape, it is crucial to provide support and reassurance to the victim. The nurse should inform the client that it was not her fault and offer support through the physical examination. Blaming the victim, as in choice A, is inappropriate and can be damaging to the client's well-being. Choice B is not the priority at this moment; the immediate focus should be on supporting the client. Choice D is victim-blaming and implies doubt about the client's report, which is harmful and not supportive. It is essential to create a safe and supportive environment for the client to facilitate healing and recovery.
What is the primary goal of family education?
- A. symptom reduction
- B. improved quality of life
- C. increased knowledge about mental illness
- D. improved caregiving skills
Correct Answer: B
Rationale: The primary goal of family education is to improve the quality of life. Family education aims to enhance the overall well-being and functioning of both the individual with the condition and their family members. While increased knowledge about mental illness may be a beneficial outcome, it is not the primary objective of family education. Symptom reduction is more commonly associated with psychoeducation rather than family education. Improving caregiving skills is a component of family education, but the primary focus is on improving the quality of life for everyone involved in the caregiving process.