Question

A nurse is caring for a client who states, "l am too embarrassed to tell anyone what I did last night." Which of the following responses should the nurse make?

Answer 1

Correct Answers:

"Let's discuss what you feel embarrassed about."

Rationale :

💎The nurse should offer non-judgmental support by inviting the client to discuss their feelings of embarrassment.

💎This encourages open communication and provides the client with an opportunity to express their thoughts and emotions.

💎Saying, "Let's discuss what you feel embarrassed about," helps to normalize the client's feelings and allows them to begin processing the situation in a safe and supportive environment.

💎The other responses may unintentionally minimize the client’s emotions or invalidate their experiences.

💎 For example, "You shouldn’t feel embarrassed to talk to me" could make the client feel shamed for having the emotion.

💎“Lots of people feel ashamed to tell their secrets" also dismisses the client’s individual experience, which may cause further distress.

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Answer 2

Correct Answers:

Geriatric Depression Scale

Rationale :

📍The Geriatric Depression Scale is specifically designed to assess for depression in older adults, who may not always show classic signs of depression, and is essential in identifying mood disorders that can affect their overall well-being.

📍Pain Assessment in Advanced Dementia Scale is used to assess pain in individuals with advanced dementia, not for general depression screening in older adults.

📍The CAGE Questionnaire is used to screen for alcohol use disorder rather than depression, and the Denver II Developmental Screening Test is designed for children, not adults.

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Answer 3

Correct Answers:

"Can you tell me how you have been feeling lately?"

Rationale :

♦️This open-ended question allows the nurse to assess the client’s emotional state and understand the context of their behavior, encouraging the client to share their feelings without judgment.

♦️Giving away personal belongings can be a sign of hopelessness or preparation for death, which is an important indicator of suicidal ideation.

♦️The nurse needs to explore these feelings further to ensure the client’s safety.

♦️Asking “Why did you feel like giving away your belongings?” may sound accusatory or lead to defensiveness, while “Everyone feels a little down sometimes” minimizes the gravity of the situation.

♦️"You should find a support group to attend" is a premature response before understanding the full emotional context.

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Answer 4

Correct Answers:

Blood glucose 256 mg/dL (74 to 106 mg/dL)

Rationale :

🟠Risperidone, an antipsychotic medication, can lead to hyperglycemia or diabetes, which may result in elevated blood glucose levels.

🟠 A value of 256 mg/dL is significantly above the normal range, indicating the need for immediate action.

🟠Sodium, WBC count, and platelets are all within the normal range for this client and do not pose an immediate concern.

🟠However, hyperglycemia should be addressed promptly to prevent complications such as diabetic ketoacidosis or long-term damage to organs.

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Answer 5

Correct Answers:

Varenicline

Rationale :

📌Varenicline is a nicotine receptor partial agonist used to help individuals quit smoking by reducing cravings and withdrawal symptoms.

📌 It is commonly prescribed to aid in smoking cessation.

📌Naltrexone is used to treat alcohol or opioid use disorders rather than smoking cessation.

📌Donepezil is used in the treatment of Alzheimer’s disease, and disulfiram is used for alcohol dependence, not for smoking cessation.

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Answer 6

Correct Answers:

Obtain a prescription for seclusion within 30 minutes.

Rationale :

⏺️Seclusion is a form of restraint and is legally required to have a provider's order within 30 minutes of its initiation to ensure compliance with regulations and client safety.

⏺️Documenting every 60 minutes is too long to wait, and seclusion should not last longer than necessary—it should always be reviewed and ordered regularly.

⏺️Monitoring vital signs every 4 hours is not sufficient for a client in seclusion; more frequent monitoring is necessary, especially in the immediate period following seclusion.

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Answer 7

Correct Answers:

The client is constantly talking.

Rationale :

🟢Pressured speech, or constant talking, is a hallmark symptom of mania in bipolar disorder.

🟢During manic episodes, clients often exhibit racing thoughts that cause them to speak rapidly and incessantly, unable to stop talking.

🟢This behavior reflects the elevated and often expansive mood characteristic of mania.

🟢Mania also includes impulsivity, hyperactivity, and reduced need for sleep, but pressured speech is a clear indicator that the client’s thoughts and behavior are out of control, marking the presence of a manic state.

🟢The rapid speech makes it difficult for others to follow or interject, which can lead to poor communication and create challenges in interpersonal interactions.

🟢Clients with bipolar disorder may also display grandiosity, excessive energy, and distractibility during manic episodes, but constant talking remains one of the most prominent symptoms.

🟢Recognizing pressured speech allows the nurse to intervene early and adjust treatment to prevent the escalation of symptoms and avoid potential harm due to impulsive behaviors.

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Answer 8

Correct Answers:

The client will communicate needs.

Rationale :

💎A core goal of treating borderline personality disorder (BPD) is to help clients improve their ability to communicate needs effectively.

💎Individuals with BPD often struggle with emotional regulation and impulsive behavior, leading them to act out rather than express their feelings in a healthy way.

💎Communicating needs is a key part of dialectical behavior therapy (DBT), a therapeutic approach specifically designed to address BPD symptoms.

💎By teaching clients how to express their emotions and needs in an appropriate manner, nurses and therapists can help reduce self-harm behaviors and improve interpersonal relationships.

💎Clients with BPD may engage in extreme behaviors due to an inability to assertively communicate or ask for help, often resulting in dysfunctional relationships and feelings of abandonment.

💎Improving communication skills empowers the client to express their needs without resorting to emotional outbursts.

💎Verbalizing improved mood, attending to hygiene, and reporting a decrease in hallucinations may be secondary outcomes, but improving communication is essential for achieving long-term emotional stability.

💎Including effective communication in the treatment plan provides the client with a tangible and achievable goal, increasing their chances of success in therapy.

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Answer 9

Correct Answers:

Preoccupation with details

Rationale :

🟢Obsessive-compulsive personality disorder (OCPD) is characterized by a preoccupation with orderliness, perfectionism, and attention to detail.

🟢Clients with OCPD often become fixated on rules, schedules, and routines, which can interfere with their ability to complete tasks efficiently.

🟢These clients may struggle with flexibility and may spend excessive time on small details that others might not consider important, often resulting in inefficiency and frustration.

🟢Their rigid adherence to rules and standards often interferes with their ability to be adaptable in social and professional settings.

🟢Unlike obsessive-compulsive disorder (OCD), which involves distressing obsessions and compulsive behaviors aimed at reducing anxiety, OCPD is more about an excessive need for control and perfectionism in daily life.

🟢Clients with OCPD tend to be highly critical of others and themselves, especially when things do not meet their standards.

🟢This preoccupation with details can result in strained relationships and difficulty functioning in situations requiring flexibility.

🟢Understanding the nature of preoccupation with details allows the nurse to develop a treatment plan that addresses the core issues of perfectionism and helps the client to work on adaptability and emotional regulation.

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Answer 10

Correct Answers:

Use short, simple sentences when speaking to the client.

Rationale :

⏺️When a client is experiencing moderate anxiety, it is important for the nurse to provide clear and concise communication to avoid overwhelming the client.

⏺️Using short, simple sentences helps the client better understand the information, reduces confusion, and alleviates additional stress.

⏺️Moderate anxiety can impair the client’s ability to process complex information, so using easy-to-understand language ensures that the client retains the essential details about the procedure and what to expect.

⏺️While providing detailed explanations is important for some clients, it may overwhelm a client with moderate anxiety, causing them to lose focus or miss critical information.

⏺️Showing a 30-minute teaching video may be too long and may exacerbate anxiety rather than calming the client.

⏺️Additionally, avoiding questions would hinder the nurse’s ability to assess the client’s understanding and clarify any concerns.

⏺️By using simple communication, the nurse promotes understanding and helps to reduce anxiety in preparation for the procedure.

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QLexNursing

1 :
A nurse is caring for a client who states, "l am too embarrassed to tell anyone what I did last night." Which of the following responses should the nurse make?

2 :
A nurse is performing screening assessments for active older adult clients at a community clinic. Which of the following tests should the nurse include in the screening?

3 :
A nurse is caring for a client who has major depressive disorder and states that he has given away his personal belongings. Which of the following responses should the nurse make?

4 :
A nurse is reviewing laboratory results of a client who has schizophrenia and is taking risperidone. For which of the following findings should the nurse notify the provider?

5 :
A nurse is caring for a client who is seeking help to quit smoking. Which of the following prescriptions should the nurse expect the provider to prescribe?

6 :
A nurse in an acute care mental health facility is caring for a client who has been placed in seclusion following an acute violent episode. Which of the following actions should the nurse take?

7 :
A nurse in a rehabilitation center is caring for a client who has bipolar disorder. Which of the following actions by the client indicates mania?

8 :
A nurse is caring for a client who has borderline personality disorder. Which of the following outcomes should the nurse include in the treatment plan?

9 :
A nurse is caring for a client who has obsessive-compulsive personality disorder. Which of the following findings should the nurse expect?

10 :
A nurse is preparing to teach a client who has moderate anxiety about what to expect after their upcoming cardiac catheterization. Which of the following actions should the nurse plan to take?

QLexNursing

1 : A nurse is caring for a client who states, "l am too embarrassed to tell anyone what I did last night." Which of the following responses should the nurse make?

2 : A nurse is performing screening assessments for active older adult clients at a community clinic. Which of the following tests should the nurse include in the screening?

3 : A nurse is caring for a client who has major depressive disorder and states that he has given away his personal belongings. Which of the following responses should the nurse make?

4 : A nurse is reviewing laboratory results of a client who has schizophrenia and is taking risperidone. For which of the following findings should the nurse notify the provider?

5 : A nurse is caring for a client who is seeking help to quit smoking. Which of the following prescriptions should the nurse expect the provider to prescribe?

6 : A nurse in an acute care mental health facility is caring for a client who has been placed in seclusion following an acute violent episode. Which of the following actions should the nurse take?

7 : A nurse in a rehabilitation center is caring for a client who has bipolar disorder. Which of the following actions by the client indicates mania?

8 : A nurse is caring for a client who has borderline personality disorder. Which of the following outcomes should the nurse include in the treatment plan?

9 : A nurse is caring for a client who has obsessive-compulsive personality disorder. Which of the following findings should the nurse expect?

10 : A nurse is preparing to teach a client who has moderate anxiety about what to expect after their upcoming cardiac catheterization. Which of the following actions should the nurse plan to take?

1 :
A nurse is caring for a client who states, "l am too embarrassed to tell anyone what I did last night." Which of the following responses should the nurse make?

2 :
A nurse is performing screening assessments for active older adult clients at a community clinic. Which of the following tests should the nurse include in the screening?

3 :
A nurse is caring for a client who has major depressive disorder and states that he has given away his personal belongings. Which of the following responses should the nurse make?

4 :
A nurse is reviewing laboratory results of a client who has schizophrenia and is taking risperidone. For which of the following findings should the nurse notify the provider?

5 :
A nurse is caring for a client who is seeking help to quit smoking. Which of the following prescriptions should the nurse expect the provider to prescribe?

6 :
A nurse in an acute care mental health facility is caring for a client who has been placed in seclusion following an acute violent episode. Which of the following actions should the nurse take?

7 :
A nurse in a rehabilitation center is caring for a client who has bipolar disorder. Which of the following actions by the client indicates mania?

8 :
A nurse is caring for a client who has borderline personality disorder. Which of the following outcomes should the nurse include in the treatment plan?

9 :
A nurse is caring for a client who has obsessive-compulsive personality disorder. Which of the following findings should the nurse expect?

10 :
A nurse is preparing to teach a client who has moderate anxiety about what to expect after their upcoming cardiac catheterization. Which of the following actions should the nurse plan to take?