Question

A nurse is discharging a client who was admitted for the treatment of alcohol withdrawal. Which of the following resources should the nurse recommend to the client?

Answer 1

Correct Answers:

A 12-step program.

Rationale :

🔷 12-step programs like Alcoholics Anonymous provide a structured and supportive framework for individuals recovering from alcohol use disorder.

🔷 These programs promote peer accountability, emotional support, and spiritual growth, which are essential for maintaining sobriety.

🔷 Participation helps individuals understand triggers, develop coping strategies, and stay committed to relapse prevention.

🔷 The program is widely available, free of charge, and accessible in most communities.

🔷 Referring the client to a 12-step program at discharge supports a continuity of care beyond the hospital setting.

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Answer 2

Correct Answers:

Validation therapy.

Rationale :

🔷 Validation therapy involves acknowledging the client’s perceived reality rather than challenging it.

🔷 In clients with dementia, using validation decreases anxiety, fosters trust, and maintains emotional comfort.

🔷 It allows the nurse to build rapport and avoid confrontation, which can escalate agitation.

🔷 This approach supports the client’s psychological needs and preserves their dignity.

🔷 It is particularly effective in late-stage dementia, where orientation techniques are no longer beneficial.

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Answer 3

Correct Answers:

Word salad.

Rationale :

🔷 Word salad refers to a group of incoherent words that lack logical meaning or connection.

🔷 This speech pattern is characteristic of disorganized schizophrenia, where thought processes are severely fragmented.

🔷 The client’s sentence lacks structure and fails to convey any understandable content.

🔷 It reflects a disruption in cognitive processing, making communication ineffective.

🔷 Documenting this using correct terminology supports accurate diagnosis and treatment planning.

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Answer 4

Correct Answers:

"l' d like to know more about what happened. Let's sit and talk."

Rationale :

🔷 This response uses therapeutic communication to open a nonjudgmental conversation with the parent.

🔷 It encourages the client to share details in a supportive and safe environment.

🔷 Building rapport and trust is critical in suspected child abuse cases before taking further legal steps.

🔷 It also helps gather accurate information needed for proper reporting and intervention.

🔷 The nurse remains empathetic and professional, aligning with trauma-informed care principles.

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Answer 5

Correct Answers:

Grandiosity.
Flight of ideas.
Hyperactivity.

Rationale :

Grandiosity

🔶Clients experiencing a manic episode often display inflated self-esteem or an exaggerated sense of importance, which is termed grandiosity.

🔶 They may believe they possess special abilities or powers, or that they are famous or influential despite clear evidence to the contrary.

🔶 This symptom reflects the elevated mood and impaired judgment characteristic of mania.

Flight of ideas

🔶 Flight of ideas involves rapidly shifting from one thought to another in a way that makes speech difficult to follow.

🔶 The client's thoughts are often loosely connected or completely unrelated, making communication disorganized.

🔶This is a prominent sign of manic thinking patterns and often includes pressured speech.

Hyperactivity

🔶 During a manic episode, clients frequently engage in excessive motor activity, which may appear purposeless or overly goal-directed.

🔶 They may participate in numerous tasks at once without completing any, reflecting impaired focus and distractibility.

🔶 Hyperactivity is a defining feature that contributes to physical exhaustion and risk of harm.

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Answer 6

Correct Answers:

"ECT is delivered through electrodes attached to the head."

Rationale :

🔷 Electroconvulsive therapy (ECT) is administered by placing electrodes on the scalp to induce controlled seizures.

🔷 It is typically used for treatment-resistant depression, severe mood disorders, and certain psychotic conditions.

🔷 The procedure is conducted under general anesthesia with muscle relaxants to prevent injury.

🔷 The nurse must prepare the client by explaining the process and purpose to reduce anxiety.

🔷 Educating the client with factual and accurate information helps in obtaining informed consent.

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Answer 7

Correct Answers:

Use simple words to describe procedures to the client.

Rationale :

🔷 Clients with panic disorder often experience heightened sensitivity to stimuli and may misinterpret complex explanations.

🔷 Using simple and clear language helps decrease cognitive overload and promotes a sense of safety.

🔷 This technique improves understanding, reduces fear, and facilitates cooperation during care.

🔷 It demonstrates compassionate communication tailored to the client's emotional state.

🔷 Effective communication helps prevent escalation of panic symptoms in stressful settings.

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Answer 8

Correct Answers:

Ensure the client's ex-partner is notified of the threat.

Rationale :

🔷 Nurses have a legal duty to warn potential victims when a specific threat is disclosed.

🔷 This duty is based on the Tarasoff ruling, which upholds the right to protect potential victims from harm.

🔷 The nurse must collaborate with the treatment team and legal authorities to ensure safety measures.

🔷 Timely action prevents potential violence and protects both the client and the public.

🔷 Documentation and notification must be prompt and accurate for legal and ethical compliance.

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Answer 9

Correct Answers:

A client who has somatic symptom disorder.

Rationale :

🔷 Assertiveness training helps individuals express their needs without being passive or aggressive.

🔷 Clients with somatic symptom disorder often suppress emotions, which may manifest as physical symptoms.

🔷 Training empowers them to communicate more effectively and reduce stress-related symptoms.

🔷 It supports the development of adaptive coping skills and promotes emotional well-being.

🔷 This intervention aligns with the psychological treatment plan for somatic disorders.

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Answer 10

Correct Answers:

The child has had no immunization since birth.

Rationale :

🔷 Failure to provide immunizations is a sign of medical neglect, which endangers the child’s health.

🔷 Immunizations are essential for preventing serious communicable diseases in early childhood.

🔷 Neglect is defined by the absence of basic health care, nutrition, or safety for the child.

🔷 This requires mandatory reporting by the nurse to child protective services.

🔷 Early identification protects the child from further harm or developmental risks.

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QLexNursing

1 :
A nurse is discharging a client who was admitted for the treatment of alcohol withdrawal. Which of the following resources should the nurse recommend to the client?

2 :
A nurse is caring for a client who has dementia and insists that a doll is their infant child. Which of the following behavioral management techniques should the nurse use when interacting with the client?

3 :
A nurse in an acute care facility is assessing a client who has schizophrenia. The client states, "Walk tall broom short dog bell." The nurse should document the client's speech as which of the following speech patterns?

4 :
A nurse in an urgent care clinic is caring for a school-age child who has several visible bruises. The child's parent states, "My partner got fired today and came home angry. I don't think this will happen again." Which of the following responses should the nurse make?

5 :
A nurse is conducting an admission assessment for a client who is experiencing a manic episode of bipolar disorder. Which of the following behaviors should the nurse expect? (Select all that apply)

6 :
A nurse is preparing to teach a client who has major depressive disorder and is scheduled to undergo electroconvulsive therapy (ECT). Which of the following statements should the nurse include in the teaching?

7 :
A nurse is creating a plan of care for a client who has panic disorder. Which of the following interventions should the nurse include?

8 :
A nurse on a medical-surgical unit is caring for a client who tells the nurse about their intentions to harm an ex-partner. Which of the following actions is a legal duty of the nurse?

9 :
A nurse on a mental health unit is planning a group therapy session about assertiveness training. For which of the following clients should the nurse recommend the training?

10 :
A nurse is conducting a child maltreatment screening of a family who has a toddler. Which of the following findings should the nurse identify as an indicator of possible child neglect?

QLexNursing

1 : A nurse is discharging a client who was admitted for the treatment of alcohol withdrawal. Which of the following resources should the nurse recommend to the client?

2 : A nurse is caring for a client who has dementia and insists that a doll is their infant child. Which of the following behavioral management techniques should the nurse use when interacting with the client?

3 : A nurse in an acute care facility is assessing a client who has schizophrenia. The client states, "Walk tall broom short dog bell." The nurse should document the client's speech as which of the following speech patterns?

4 : A nurse in an urgent care clinic is caring for a school-age child who has several visible bruises. The child's parent states, "My partner got fired today and came home angry. I don't think this will happen again." Which of the following responses should the nurse make?

5 : A nurse is conducting an admission assessment for a client who is experiencing a manic episode of bipolar disorder. Which of the following behaviors should the nurse expect? (Select all that apply)

6 : A nurse is preparing to teach a client who has major depressive disorder and is scheduled to undergo electroconvulsive therapy (ECT). Which of the following statements should the nurse include in the teaching?

7 : A nurse is creating a plan of care for a client who has panic disorder. Which of the following interventions should the nurse include?

8 : A nurse on a medical-surgical unit is caring for a client who tells the nurse about their intentions to harm an ex-partner. Which of the following actions is a legal duty of the nurse?

9 : A nurse on a mental health unit is planning a group therapy session about assertiveness training. For which of the following clients should the nurse recommend the training?

10 : A nurse is conducting a child maltreatment screening of a family who has a toddler. Which of the following findings should the nurse identify as an indicator of possible child neglect?

1 :
A nurse is discharging a client who was admitted for the treatment of alcohol withdrawal. Which of the following resources should the nurse recommend to the client?

2 :
A nurse is caring for a client who has dementia and insists that a doll is their infant child. Which of the following behavioral management techniques should the nurse use when interacting with the client?

3 :
A nurse in an acute care facility is assessing a client who has schizophrenia. The client states, "Walk tall broom short dog bell." The nurse should document the client's speech as which of the following speech patterns?

4 :
A nurse in an urgent care clinic is caring for a school-age child who has several visible bruises. The child's parent states, "My partner got fired today and came home angry. I don't think this will happen again." Which of the following responses should the nurse make?

5 :
A nurse is conducting an admission assessment for a client who is experiencing a manic episode of bipolar disorder. Which of the following behaviors should the nurse expect? (Select all that apply)

6 :
A nurse is preparing to teach a client who has major depressive disorder and is scheduled to undergo electroconvulsive therapy (ECT). Which of the following statements should the nurse include in the teaching?

7 :
A nurse is creating a plan of care for a client who has panic disorder. Which of the following interventions should the nurse include?

8 :
A nurse on a medical-surgical unit is caring for a client who tells the nurse about their intentions to harm an ex-partner. Which of the following actions is a legal duty of the nurse?

9 :
A nurse on a mental health unit is planning a group therapy session about assertiveness training. For which of the following clients should the nurse recommend the training?

10 :
A nurse is conducting a child maltreatment screening of a family who has a toddler. Which of the following findings should the nurse identify as an indicator of possible child neglect?