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Why is it important for the nurse to inform the family about the client's situation?
- A. To decrease the client's anxiety
- B. To help the family better adapt to necessary role changes
- C. To improve communication between family and nursing staff
- D. To ensure a more relaxed atmosphere for the client
Correct Answer: B
Rationale: It is crucial for the nurse to inform the family about the client's situation to help them better adapt to necessary role changes. By providing early notification, the family can start preparing for potential adjustments. While reducing the client's anxiety and improving communication with the nursing staff are important, the primary purpose is to assist the family in undertaking the required role changes. Creating a relaxed atmosphere for the client, although beneficial, is not the main objective in this situation.
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Which behavior indicates that the client has learned the most effective method to cope with anger?
- A. Goes for a long jog
- B. Talks about the anger
- C. Goes outside and screams
- D. Focuses on cause of anger
Correct Answer: B
Rationale: The correct answer is 'Talks about the anger.' This response indicates that the client has learned a positive coping method, as discussing angry feelings is a healthier way of dealing with anger. Talking about anger allows for expression and communication, leading to a better understanding of the emotions involved. Going for a long jog or screaming outside may provide temporary relief, but they do not address the root cause or help in processing the emotions effectively. Focusing solely on the cause of anger without expressing feelings may lead to increased frustration and escalation of anger, rather than promoting constructive coping mechanisms.
Which risk factor for suicide is considered the most lethal?
- A. History of alcohol and drug abuse
- B. Previous high-lethality suicide attempts
- C. Recent withdrawal from friends
- D. Disturbance of family dynamics
Correct Answer: B
Rationale: The correct answer is 'Previous high-lethality suicide attempts.' This is the most lethal risk factor as it indicates that the individual has previously attempted suicide in a manner that could lead to death. This history increases the likelihood of future attempts. While substance abuse, like alcohol and drug use, is a significant risk factor for suicide, it is not considered the most lethal. Withdrawal from friends or social isolation can contribute to suicide risk but is not as directly deadly as high-lethality attempts. Disturbance of family dynamics can also be a stressor but does not represent the immediate lethality associated with a history of high-lethality suicide attempts.
A client is undergoing treatment for alcoholism. Twelve hours after their last drink, they develop tremors, increased heart rate, hallucinations, and seizures. Which stage of withdrawal is this client experiencing?
- A. Stage 1
- B. Stage 2
- C. Stage 3
- D. Stage 4
Correct Answer: C
Rationale: In alcohol withdrawal, stage 3 typically begins about 12-48 hours after the last drink. It includes symptoms from stages 1 and 2 like tremors, tachycardia, mild hallucinations, hyperactivity, and confusion. By stage 3, severe hallucinations and seizures can occur. Choice A, stage 1, is too early for the described symptoms. Stage 2, as described, is also too early as it typically occurs within 6-12 hours. Stage 4 is not a recognized stage in alcohol withdrawal protocols.
Which therapeutic approach would indicate the client is receiving desensitization therapy?
- A. Imagery
- B. Modeling
- C. Role playing
- D. Assertiveness training
Correct Answer: A
Rationale: The correct answer is 'Imagery.' Imagery is a therapeutic approach used in desensitization therapy. It helps in facilitating positive self-talk and involves the client initiating and controlling mental pictures to correct faulty cognitions. Modeling, role-playing, and assertiveness training are effective general behavioral approaches but are not specific to desensitization therapy.
A newly diagnosed client with human immunodeficiency virus (HIV) comments to the nurse, 'There are so many rotten people around. Why couldn't one of them get HIV instead of me?' Which statement is the nurse's best response?
- A. 'I can understand why you are afraid of dying.'
- B. 'It seems unfair that you contracted this disorder.'
- C. 'Do you really wish this disorder on someone else?'
- D. 'Have you thought of speaking with your religious adviser?'
Correct Answer: B
Rationale: The client is expressing feelings of unfairness and questioning why they have HIV. The nurse's best response is to acknowledge the client's emotions. Choice B, 'It seems unfair that you contracted this disorder,' reflects empathy and validates the client's feelings, which can help them move towards acceptance. Choice A, 'I can understand why you are afraid of dying,' introduces the topic of death, which may not be the primary concern at this stage. Choice C, 'Do you really wish this disorder on someone else?' is judgmental and could induce guilt in the client. Choice D, 'Have you thought of speaking with your religious adviser?' deflects the conversation and does not address the client's current emotional needs.