Nokea
Which question best assesses the client's long-term memory?
- A. What is your current age?
- B. What is today's date?
- C. What is your date of birth?
- D. What occurred last January?
Correct Answer: C
Rationale: Recalling date of birth tests long-term memory, as it requires retrieving well-established, distant personal information.
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If this client is typical of others with phobias, which coping mechanism has the client most likely been using to deal with the fear of flying?
- A. Suppression
- B. Compensation
- C. Avoidance
- D. Undoing
Correct Answer: C
Rationale: Avoidance is the primary coping mechanism in phobias, as clients steer clear of the feared stimulus, such as refusing to fly.
The client's family asks the nurse for a list of organizations where they can go for support during this difficult time. Which resource is most appropriate in this situation?
- A. Alcoholics Anonymous
- B. Recovery Anonymous
- C. Al-Anon
- D. Synanon
Correct Answer: C
Rationale: Al-Anon is specifically designed to support family members of individuals with alcoholism, providing them with coping strategies and emotional support.
The nurse is teaching the client with a substance abuse disorder about 12-step self-help programs such as AA. The nurse informs the client that the major principle associated with this 12-step program is what principle?
- A. Substance abuse disorders can be cured with total abstinence.
- B. Normal substance use can resume with the guidance and support of others.
- C. Acceptance of powerlessness over a substance is the first step in recovery.
- D. Substance abuse is a weakness that can be overcome through a belief in God.
Correct Answer: C
Rationale: AA’s first step is admitting powerlessness (C). Addiction is a disease not curable (A) or resumable (B) and not a weakness; higher power is personal (D).
If the rape victim shares all of the following information during a group session, which findings are most indicative of a severe adjustment reaction? Select all that apply.
- A. The victim reports feeling somewhat anxious.
- B. The victim describes having sporadic nightmares.
- C. The victim has lost weight and eats out of habit.
- D. The victim has occasional doubts about self-worth.
- E. The victim refuses to have sexual relations.
- F. The victim has started to drink wine before bedtime.
Correct Answer: B,C,E,F
Rationale: Nightmares, weight loss, sexual avoidance, and new alcohol use indicate significant distress and maladaptive coping, suggestive of a severe adjustment reaction.
The nurse is unavoidably late in changing the dressing on the client’s leg. The client reacts by becoming verbally aggressive and telling the nurse “None of you can be trusted. You all just make promises you never intend to keep.” Which should be the nurse’s initial action?
- A. Alert other staff to the client’s apparent escalation.
- B. Ask why the client is overreacting to the situation.
- C. Leave the room until the client has regained control.
- D. Apologize to the client for being late with the treatment.
Correct Answer: D
Rationale: Apologizing (D) validates the client’s distress and acknowledges the nurse’s role de-escalating the situation. Alerting staff (A) is secondary asking why (B) may escalate defensiveness and leaving (C) avoids communication.