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Which of the following factors increases a client's risk of experiencing a crisis?
- A. Stable employment
- B. Positive coping skills
- C. History of trauma
- D. Strong social support system
Correct Answer: C
Rationale: The correct answer is C: History of trauma. A history of trauma increases a client's risk of experiencing a crisis due to unresolved emotional wounds, triggering distressing memories, and impacting their ability to cope effectively. Trauma can lead to heightened stress responses and exacerbate mental health issues, making individuals more vulnerable to crises.
Incorrect choices: A) Stable employment and D) Strong social support system are protective factors that reduce the risk of crises. B) Positive coping skills enhance resilience and help individuals manage stress effectively, decreasing crisis likelihood.
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A male client is admitted to the unit with a possible diagnosis of delirium. Which statement by the client's wife best supports the diagnosis?
- A. Since his mother died, he has not been feeling well.
- B. My husband just didn't seem to know what he was doing. He has been forgetful for years.
- C. The changes in his behavior came on so quickly! I wasn't sure what was happening.
- D. This is supposed to happen when you get old, right?
Correct Answer: C
Rationale: The correct answer is C because delirium is characterized by a rapid onset of confusion, changes in behavior, and altered mental status. The wife's statement about the changes in behavior coming on quickly aligns with this key characteristic of delirium.
Choice A is incorrect because the client's feelings after his mother's death are not necessarily related to delirium. Choice B is incorrect because long-term forgetfulness is more indicative of dementia rather than delirium. Choice D is incorrect because delirium is not a normal part of aging.
The nurse is planning care for a child who has intermittent explosive disorder (IED). The nurse should identify which of the following goals are appropriate for this client? (Select All that Apply.)
- A. The child will demonstrate effective problem-solving skills.
- B. The child will acknowledge they have a genetic disorder.
- C. The child will verbalize age-appropriate feelings of self-worth.
- D. The family will be able to express their concerns.
- E. The child will sign a behavior contract.
- F. The child will learn to isolate when feeling angry.
Correct Answer: A,E,F
Rationale: Correct Answer: A, E, F
Rationale:
A: The child demonstrating effective problem-solving skills is crucial for managing IED episodes.
E: Signing a behavior contract helps set clear expectations and consequences for behavior, aiding in self-regulation.
F: Learning to isolate when feeling angry can prevent harm and give time to calm down, a key skill for managing IED.
Incorrect Choices:
B: Acknowledging a genetic disorder is not relevant to managing IED.
C: While important, verbalizing feelings of self-worth may not directly address the impulsivity of IED.
D: Expressing concerns is valuable but not a direct goal for managing IED.
Charles, the nurse, is working in an emergency department and is assessing a preschool-age child who reports abdominal pain. Which of the following findings should alert the nurse to possible abuse (select all that apply)
- A. Areas of ecchymosis on the torso.
- B. Mismatched clothing
- C. Abrasions on knees
- D. Abdominal rebound tenderness
- E. Round burn marks on forearms
Correct Answer: A,E
Rationale: The correct answers are A and E. Ecchymosis on the torso may indicate physical abuse, and burn marks on the forearms suggest possible abuse as well. Mismatched clothing (B) is not a direct indicator of abuse but may suggest neglect. Abrasions on knees (C) are common in preschool-age children and do not specifically point to abuse. Abdominal rebound tenderness (D) is a medical finding that may indicate a health issue but does not directly correlate with abuse. Overall, A and E are the most concerning findings that should alert the nurse to possible abuse.
A nurse in the acute mental health unit is admitting a new client with an eating disorder. The nurse is aware that which of the following are considered comorbidities of eating disorders? (Select all that apply.)
- A. Anxiety
- B. Depression
- C. Obsessive-compulsive disorder
- D. Schizophrenia
- E. Breathing-related sleep disorder
Correct Answer: A,B,C
Rationale: The correct answer is A, B, and C. Anxiety, depression, and obsessive-compulsive disorder are commonly seen as comorbidities in individuals with eating disorders. Anxiety and depression are often present due to the psychological stress and emotional turmoil associated with the eating disorder. Obsessive-compulsive disorder can manifest in obsessive thoughts about food, weight, and body image, as well as compulsive behaviors related to eating and exercise. Schizophrenia and breathing-related sleep disorder are not typically associated with eating disorders, making choices D and E incorrect. It is essential for the nurse to be aware of these comorbidities to provide holistic care to the client.
A nurse is planning care for a client who is postoperative following a thyroidectomy. Which of the following interventions should the nurse include in the plan?
- A. Hyperextend the client's neck.
- B. Instruct the client to deep breathe every 4 hr.
- C. Place the head of the client's bed in the flat position.
- D. Check the client's voice every 2 hr.
Correct Answer: B,D
Rationale: The correct answers are B and D. Instructing the client to deep breathe every 4 hours helps prevent respiratory complications post-thyroidectomy. Checking the client's voice every 2 hours is important to monitor for vocal cord damage, a potential complication. Choice A is incorrect as hyperextending the client's neck can put strain on the surgical site. Choice C is incorrect as the head of the bed should be elevated to reduce swelling and promote drainage.