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A teenage client asks the nurse, "Do you think I should tell my parents about my sexuality?"
What is the nurse's best response?
1. "What do you think you should do?"
2. "Absolutely, I think you should tell your parents."
3. "Don't you think your parents have the right to know about your sexuality?"
4. "I do not think now is the right time to tell your parents. Wait until you are 21." - CORRECT
ANSWER ✔️✔️ -1. Correct: It is better to say "What do you think you should do?" This helps the
client reflect on options and does not have the nurse tell the client what to do. It is much more
therapeutic to help the client make the decision for themselves, instead of the nurse. This
prevents any biases from impacting the outcome.
2. Incorrect: All of these responses give advice to the client. Telling the client what to do or how
to behave which implies that the nurse knows what is best and that the client is not capable of
making any decisions.
3. Incorrect: All of these responses give advice to the client. Telling the client what to do or how
to behave which implies that the nurse knows what is best and that the client is not capable of
making any decisions.
4. Incorrect: All of these responses give advice to the client. Telling the client what to do or how
to behave which implies that the nurse knows what is best and that the client is not capable of
making any decisions.
,The nurse is caring for a client who presents to the mental health unit following a violent
altercation with the spouse. The client has numerous bruises on the face, chest, and back. There
is one laceration where spouse "came at me" with a knife. At this time, what is most likely to be
the mood of the perpetrator in this situation?
1. Extreme anger
2. Anxiety
3. Kindness
4. Irritability - CORRECT ANSWER ✔️✔️ -3. Correct: The perpetrator has completed the acute
battering phase and has now likely entered the honeymoon phase with extreme kindness and acts
of love. The attacker is now calm after the tension has been released. You may witness
remorseful and apologetic behaviors like bringing gifts and promises of love.
1. Incorrect: The anger phase is likely over after the attacker has beaten the victim. This anger
building stage is called tension building stage and is characterized by minor incidents like
pushing, shoving and verbal abuse. During this time the abused spouse may accept the abuse for
fear of it getting worse so the abuser rationalizes that the behavior is acceptable. The abuser may
even turn to alcohol and drugs to curb the anger. The extreme anger exhibited during the acute
battering stage. The abuser releases the built-up anger and tension by brutal and uncontrollable
beatings. After the beating the client is calm and described as "in shock" or have have amnesia of
the event. You also see extreme anger in the escalation/de-escalation stage.
2. Incorrect: The tension or anxiety would be felt during the tension-building phase. This anger
building stage is called tension building stage and is characterized by minor incidents like
pushing, shoving and verbal abuse. During this time the abused spouse may accept the abuse for
,fear of it getting worse so the abuser rationalizes that the behavior is acceptable. The abuser may
even turn to alcohol and drugs to curb the anger. The extreme anger exhibited during the acute
battering stage. The abuser releases the built-up anger and tension by brutal and uncontrollable
beatings. After the beating the client is calm and described as "in shock" or have have amnesia of
the event. You also see extreme anger in the escalation/de-escalation stage.
4. Incorrect: Irritability would
A teenage client with asthma reports becoming very anxious and fearful each time an asthma
attack occurs. What would be the nurse's best response to the client?
1. "I understand that you feel anxious. But you must stop this behavior."
2. "The feelings that you described can occur in individuals with asthma. You may find that
learning relaxation exercises may help."
3. "I am concerned that feeling anxious during an asthma attack means you need more education
about asthma."
4. "Everyone with asthma experiences tough times with their symptoms. You are learning to
manage your asthma." - CORRECT ANSWER ✔️✔️ -2. Correct: This statement acknowledges
the client's feelings and then provides a suggested strategy that has been found to be useful in
clients with anxiety and fear associated with asthma.
1. Incorrect: The nurse states understanding but then tells the client to stop the behavior without
providing any helpful suggestions.
3. Incorrect: This response is disagreeing with the client's feelings and psychosocial response by
stating that more education about asthma will prevent anxiety during an asthma attack.
, 4. Incorrect: This response dismisses and belittles the client's feelings and psychosocial response
associated with asthma. By stating "everyone with asthma", the nurse is making a stereotypical
response. This does not promote expressions of feelings by the client.
Which nursing intervention should the nurse include when caring for a client with Alzheimer's
disease being admitted to a long term care facility?
1. Offer multiple environmental stimuli at the same time to provide distraction.
2. Encourage the client to participate in activities such as board games.
3. Restrain the client in a chair to prevent falls when sundowning occurs.
4. Involve the client in supervised walking as a routine. - CORRECT ANSWER ✔️✔️ -4. Correct:
A regular routine and physical activity help client's with Alzheimer's disease maintain abilities
for a longer period of time. Physical activities promote strength, agility and balance. The client's
walking should be supervised for client safety issues.
1. Incorrect: Environmental stimuli should be limited with clients with Alzheimer's Disease. The
client can become agitated and/or more disoriented with an increase in environmental stimuli.
2. Incorrect: Board games would not be appropriate due to the client's cognitive and memory
impairment. Board games require complex cognitive actions.
3. Incorrect: Restraints should be avoided because they increase agitation. The client may
become agitated by the restriction of he restraints. Also the client may perceive the restraints as a
threat.