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Which thought process would the nurse document the mental health client is experiencing after the client says, 'The FBI is out to kill me'?
- A. Hallucinations
- B. Error in judgment
- C. Delusion of persecution
- D. Self-accusatory delusion
Correct Answer: C
Rationale: The nurse would document that the client is experiencing a delusion of persecution. A delusion of persecution is a fixed and firm belief of being harassed, in danger, or at the mercy of others, as illustrated by 'The FBI is out to kill me.' Hallucinations are perceived experiences that occur without actual sensory stimulation. Error in judgment refers to poor decision-making, not a distortion of reality like a delusion. A self-accusatory delusion involves accepting blame for an act that was never committed or a feeling that was never acted on. Therefore, the correct choice is 'Delusion of persecution.'
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What is a common reason why clients abuse alcohol?
- A. To blunt reality
- B. To precipitate euphoria
- C. To promote social interaction
- D. To stimulate the central nervous system
Correct Answer: A
Rationale: Clients often abuse alcohol to blunt reality. Alcohol, by depressing the central nervous system and distorting or altering reality, can reduce anxiety. It is not primarily used to precipitate euphoria; instead, it may lead to mood swings, impaired judgment, and aggressive behavior. While alcohol can be used as a social lubricant, individuals with alcohol use disorder often drink in isolation. Moreover, excessive alcohol consumption can result in inappropriate and aggressive behaviors that hinder social interactions. It's important to note that alcohol is a depressant, unlike stimulants such as amphetamines and cocaine.
Which therapeutic technique can the nurse use when an anxious client exhibits pressured and rambling speech?
- A. Touch
- B. Silence
- C. Focusing
- D. Summarizing
Correct Answer: C
Rationale: Focusing is the appropriate therapeutic technique to use when an anxious client exhibits pressured and rambling speech. By focusing on one specific aspect, the intended meaning is easier to understand and helps the client stay on track. Touch is not recommended in this scenario as it can invade the client's personal space and potentially increase anxiety. Silence may allow the client to continue rambling without addressing the underlying concerns. Summarizing requires the identification and exploration of the client's concerns, which may be challenging when the speech is pressured and disorganized.
Which of the following examples indicates that the nurse is giving recognition as a form of therapeutic communication?
- A. You need to take your medicine now, Adam.
- B. Jill, your father is trying to make amends with you.
- C. The physician wants to meet with you and your husband, Amy.
- D. Linda, you brushed your hair this morning.
Correct Answer: A
Rationale: Recognition is a form of therapeutic communication in which the nurse points out a positive aspect of the client's behavior. Noting that a client brushed her hair herself indicates that the nurse recognizes the client's attempts at self-care. This recognition shows the client that the nurse is paying attention and may be open to further communication. Choices A, B, and C do not demonstrate recognition. Choice A focuses on a directive statement, Choice B involves informing the client about a situation without acknowledging their actions, and Choice C informs the client about a meeting without providing recognition for any behavior.
A nurse is caring for a client with agoraphobia. Which signs and symptoms would the nurse anticipate? Select all that apply.
- A. panic attacks
- B. impaired short-term memory
- C. auditory hallucinations
- D. inability to leave home
Correct Answer: A,D
Rationale: Agoraphobia involves panic attacks and fear of leaving safe environments, leading to inability to leave home. Memory issues and hallucinations are not typical.
During a survey, the community nurse meets a client who has not visited a gynecologist after the birth of her second child. The client says that her mother or sister never had annual gynecologic examinations. Which factor is influencing the client's health practices?
- A. Spiritual beliefs
- B. Family practices
- C. Emotional factors
- D. Cultural background
Correct Answer: B
Rationale: The correct answer is 'Family practices.' In this scenario, the client's health practices are influenced by the fact that her family members never had annual gynecologic examinations, leading her to believe that such preventive care measures are unnecessary. This highlights the impact of familial behavior on an individual's perception of healthcare. Spiritual beliefs are not the primary factor at play here; they may affect the choice of medical treatment but not the decision to seek preventive care. Emotional factors like stress or fear could influence health practices, but there is no indication of this in the client's case. Cultural background would come into play if the client followed specific health beliefs or customary practices related to illness and health restoration.