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A nurse in a mental health facility is admitting a client.
div id="exhibits">Exhibits

Complete the following sentence by using the lists of options.

The client is at risk of developing

as evidenced by the client’s
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Rationale for correct choices:

Alcohol withdrawal syndrome: The client’s BAC of 310 mg/dL indicates severe intoxication. As the alcohol clears from the system, withdrawal symptoms such as anxiety, tremors, and seizures may occur, requiring close monitoring to prevent complications like delirium tremens.
Blood alcohol level of 310 mg/dL: This elevated BAC indicates significant alcohol consumption. As the alcohol is metabolized, the client is at high risk for alcohol withdrawal syndrome and requires close observation to manage withdrawal symptoms as the BAC decreases.

Rationale for incorrect choices:

Malnutrition: While weight loss and minimal appetite may be concerning, they do not definitively indicate malnutrition. These symptoms are more likely tied to the client’s psychological distress and alcohol use rather than severe nutritional deficiency.
Alcohol intoxication: The client’s current state is intoxicated; the primary concern at this stage is managing alcohol withdrawal syndrome. Once the alcohol is metabolized, the focus will shift to preventing withdrawal complications which the client is at risk of.
Respiratory rate of 10/min: A respiratory rate of 10/min is on the low side but not dangerously low. This rate may be associated with alcohol intoxication and will require monitoring but is not immediately alarming unless the client shows signs of respiratory distress.
Weight loss over the past 3 months and minimal appetite: The weight loss and reduced appetite are concerning but not immediately indicative of malnutrition. These symptoms are likely due to the client’s alcohol use and emotional distress, and further assessment is needed to evaluate nutritional health.

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Correct Answer is C

Explanation

A. "I hope I can prevent them from being hospitalized again.": While this shows concern, it suggests that the client feels responsible for preventing hospitalization, which can be an unrealistic expectation and reflects potential caregiver burden rather than acceptance.
B. "I will do my best even though I feel tired all of the time.": This reflects exhaustion and a sense of being overwhelmed, but it does not necessarily indicate acceptance of the role change. The client may still be struggling with the emotional toll of caregiving.
C. "I would like to have information about support groups.": This statement indicates a proactive approach to managing the caregiving role, which suggests that the client is beginning to accept the changes and is seeking resources to help cope. It shows openness to support and adaptation to the role.
D. "It is hard to make time for my children and my family member.": This indicates that the client is struggling with balancing caregiving and family responsibilities, which suggests difficulty in fully accepting the new caregiving role.

A. "The night shift nurse is terrible." B. "If I do what I am supposed to do, it will go away." C. "I am so angry with my spouse." D. "I don't know why I am here in the first place."

Correct Answer is A

Explanation

A. "The night shift nurse is terrible.": This is an example of displacement, where the client redirects feelings of anger or frustration from a more significant issue, such as personal conflict or stress, onto an unrelated person like the night shift nurse.
B. "If I do what I am supposed to do, it will go away.": This statement reflects an attempt at problem-solving or avoidance rather than displacement. The client is trying to manage the situation directly by taking action, rather than transferring emotions.
C. "I am so angry with my spouse.": This is a direct acknowledgment of the source of the distress (the spouse) and does not involve displacement. The client is openly expressing anger rather than redirecting it onto someone or something unrelated.
D. "I don't know why I am here in the first place.": This reflects denial, where the client avoids recognizing the true reasons for being in treatment. The client is avoiding confronting their feelings or the situation but isn’t displaying displacement.

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A nurse in a mental health facility is admitting a client. div id="exhibits">Exhibits

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is working with a client who is the caregiver of a family member who has a serious mental illness. Which of the following statements by the client indicates acceptance of the role change?

Correct Answer is C

Explanation

A nurse is caring for a client who has a personality disorder. Which of the following statements made by the client indicate they are coping with the maladaptive defense mechanism of displacement?

Correct Answer is A

Explanation

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A nurse in a mental health facility is admitting a client. Exhibits A nurse is caring for a client who was admitted for alcohol use disorder, which of the following findings require follow-up by the nurse? Select all that apply.

A nurse in a mental health facility is admitting a client.
div id="exhibits">Exhibits