A nurse in an outpatient mental health clinic is assessing an adolescent client.
The nurse should expect the adolescent to be in which of the following of Erikson's stages of psychosocial development?
Trust vs mistrust.
Intimacy vs isolation.
Identity vs role confusion.
Generativity vs self-absorption.
The Correct Answer is C
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Asking the client directly about the hallucinations is essential in understanding the nature and content of the hallucinations. This information is crucial for the nurse to assess the client's mental state accurately and plan appropriate interventions. Direct communication helps establish trust and rapport with the client, making them more likely to share their experiences.
Choice B rationale:
Avoiding eye contact can create a sense of disconnection and may increase the client's anxiety. Establishing eye contact, on the other hand, communicates empathy and attentiveness, which are essential in therapeutic communication.
Choice C rationale:
Encouraging the client to lie down in a quiet room might not be the most appropriate action, as it does not address the hallucinations directly. It's important to address the hallucinations and help the client cope with them effectively.
Choice D rationale:
Referring to the hallucinations as if they are real might validate the client's experience but can also perpetuate the hallucinations. The nurse should acknowledge the client's feelings without reinforcing the false beliefs. Providing reality-based perspectives and encouraging the client to explore the origin of these hallucinations can be more beneficial.
Correct Answer is A
Explanation
Choice A rationale:
A swollen area on the calf can indicate deep vein thrombosis (DVT), which is a serious complication of immobility. Immobilization can lead to blood stasis in the veins, increasing the risk of clot formation. DVT can result in severe complications, such as pulmonary embolism, making it a critical concern that requires immediate attention.
Choice B rationale:
Increased blood pressure is not a direct complication of immobility. However, immobility can contribute to hypertension over time due to factors such as weight gain and reduced cardiovascular fitness. While hypertension is a concern, it is not an acute complication of immobility that necessitates immediate intervention.
Choice C rationale:
Decreased serum calcium levels are not a direct complication of immobility. Immobility can lead to bone density loss and potential fractures due to reduced weight-bearing activities, but it does not cause an acute decrease in serum calcium levels.
Choice D rationale:
Urinary frequency is not a typical complication of immobility. Immobility can affect the urinary system, potentially leading to urinary stasis and increased risk of urinary tract infections, but urinary frequency is not a direct result of immobility.
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