Which response would the nurse make at lunchtime to a client who is sitting alone with the head slightly tilted as if listening to something?
- A. "I know you're busy, but it's lunchtime."
- B. "Are the voices bothering you again?"
- C. "Get going; you don't want to miss lunchtime."
- D. "It's lunchtime; I'll walk with you to the dining room."
Correct Answer: D
Rationale: The statement, "It's lunchtime; I'll walk with you to the dining room," demonstrates setting limits and providing support. Hallucinations can be frightening, and the nurse's presence offers support and reality without focusing on the hallucination directly. Choice A, "I know you're busy, but it's lunchtime," does not recognize the client's need for support and direction. Choice B, "Are the voices bothering you again?", makes a judgment without sufficient evidence and overly focuses on the hallucination, failing to address the client's need for support and direction. Choice C, "Get going; you don't want to miss lunchtime," does not acknowledge the client's need for reality, support, and direction, and may come across as threatening.
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According to Erikson's theory, which behavior would the nurse expect a preschooler to exhibit?
- A. The child develops the superego.
- B. The child plays beside other children.
- C. The child concentrates on work and play.
- D. The child becomes casual about body appearance.
Correct Answer: A
Rationale: According to Erikson's theory, a preschooler develops the superego or conscience during the initiative versus guilt stage. This stage occurs around ages 3 to 6 years old. The development of the superego is crucial for the child to start understanding and internalizing societal and parental values. Choice B is incorrect because playing beside other children typically occurs during the autonomy versus shame and doubt stage, which is seen in toddlers. Choice C is incorrect as concentrating on work and play is more characteristic of the industry versus inferiority stage, typically seen in school-aged children. Choice D is incorrect because becoming casual about body appearance is more aligned with the identity versus role confusion stage, which is seen in adolescents who have a marked preoccupation with appearance and body image.
Which behavior by the client exhibits denial after a recent diagnosis?
- A. Attempts to minimize the illness
- B. Lacks an emotional response to the illness
- C. Refuses to discuss the condition with the client's spouse
- D. Expresses displeasure with the prescribed activity program
Correct Answer: A
Rationale: The correct answer is 'Attempts to minimize the illness.' This behavior is a classic sign of denial, where the individual tries to downplay the seriousness of the illness to cope with it. By minimizing the illness, the client avoids facing the reality of the situation, which is characteristic of denial. Lacking an emotional response to the illness suggests suppression of emotions rather than denial. Refusing to discuss the condition with the spouse may stem from other issues like relationship strain or fear of causing distress, but it doesn't directly indicate denial. Expressing displeasure with the prescribed activity program typically reflects displaced anger, not denial of the illness.
Which clinical findings indicate positive signs and symptoms of schizophrenia?
- A. Withdrawal, poverty of speech, inattentiveness
- B. Flat affect, decreased spontaneity, asocial behavior
- C. Hypomania, labile mood swings, episodes of euphoria
- D. Bizarre behavior, auditory hallucinations, loose associations
Correct Answer: D
Rationale: The correct answer is bizarre behavior, auditory hallucinations, and loose associations. These are positive symptoms of schizophrenia, reflecting a distortion or excess of normal function. Withdrawal, poverty of speech, inattentiveness, flat affect, decreased spontaneity, and asocial behavior are negative symptoms linked to schizophrenia, indicating a diminution or absence of normal function. Hypomania, labile mood swings, and episodes of euphoria are more characteristic of bipolar disorder, rather than schizophrenia.
What is the primary purpose served when an individual takes action to reduce anxiety?
- A. Reduction of tension
- B. Denial of the situation
- C. Avoidance of physical discomfort
- D. Resolution in decision-making
Correct Answer: A
Rationale: The primary purpose of taking action to reduce anxiety is to alleviate emotional tension and prevent the exacerbation of anxiety symptoms. By reducing tension, anxiety levels decrease, leading to a sense of comfort, safety, and security. Denial of the situation is not the goal when addressing anxiety; rather, acknowledging and managing it is crucial. While physical discomfort may accompany anxiety, the focus is on alleviating the emotional aspect to mitigate physical manifestations. Although mild anxiety can sometimes improve decision-making skills, higher levels of anxiety typically impede cognitive functions, making resolution in decision-making less likely.
A client asks the nurse, 'Should I tell my partner that I just found out I'm human immunodeficiency virus (HIV) positive?' Which is the nurse's most appropriate response?
- A. Do not tell your partner unless asked.
- B. This is a decision you alone can make.
- C. You are having difficulty deciding what to say.
- D. Tell your partner that you don't know how you became sick.
Correct Answer: C
Rationale: The most appropriate response for the nurse in this situation is to acknowledge the client's struggle in deciding what to communicate to their partner. By stating 'You are having difficulty deciding what to say,' the nurse validates the client's feelings and encourages further discussion. Option A is incorrect as it suggests withholding information unless asked, which may not align with ethical principles of honesty and transparency in relationships. Option B, while acknowledging the client's autonomy, does not provide direct support or guidance. Option D is inappropriate as it involves dishonesty by suggesting telling the partner an untruthful reason for the illness.