A nurse is caring for a client on the Mental Health Unit. The client refuses to get out of bed, go to activities, or participate in any of the unit’s programs. Which of the following responses should the nurse make?

“You should rest until you feel able to join the group.”

“I will help you get ready, and then you can rest after activities.”

“If you do not get out of bed, you will not receive your meal.”

“You really need to follow the rest of the unit and get out of bed.”

Answer and Explanation

The Correct Answer is B

Choice A Reason: While this response may seem compassionate, it does not encourage the client to engage in activities that could benefit their mental health. Allowing the client to remain isolated may reinforce feelings of helplessness or depression. It is important to motivate clients to participate in therapeutic activities to promote their recovery.

Choice B Reason: This response is supportive and offers a compromise. It acknowledges the client’s current state and provides assistance, while also gently encouraging participation in activities. By offering help and allowing for rest afterward, the nurse is using an empathetic approach to facilitate the client’s involvement in the unit’s programs.

Choice C Reason: This response is coercive and could be considered a threat. It is not therapeutic to withhold basic needs such as meals as a form of punishment or to force compliance. Such an approach can damage the nurse-client relationship and is not conducive to the client’s recovery.

Choice D Reason: This response may come across as dismissive and demanding. It does not offer support or acknowledge the client’s feelings. Telling the client what they “need” to do without offering help or understanding can lead to resistance and a lack of trust in the nurse-client relationship.

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Correct Answer is ["A","D","E","F"]

Explanation

The correct answer is: A, D, E, and F.

Choice A reason:

Muscular tension, blood pressure, and triglycerides increase. Long-term stress can lead to chronic muscle tension, elevated blood pressure, and increased triglyceride levels. Chronic muscle tension is a common response to prolonged stress, often resulting in pain and discomfort. Elevated blood pressure is a well-documented effect of chronic stress, which can increase the risk of cardiovascular diseases. Increased triglycerides are also associated with prolonged stress, contributing to metabolic syndrome and cardiovascular risk.

Choice B reason:

Epinephrine is released, increasing heart and respiratory rates. This response is more characteristic of acute stress rather than long-term stress. Epinephrine (adrenaline) is released during the “fight-or-flight” response, causing immediate increases in heart rate and respiratory rate. However, this is a short-term physiological response and not typically sustained over long periods.

Choice C reason:

Corticosteroid release increases stamina and impedes digestion. While corticosteroids like cortisol are released during stress, their primary long-term effect is not to increase stamina but to manage energy by increasing blood glucose levels through gluconeogenesis. Chronic cortisol release can indeed impede digestion by diverting energy away from non-essential functions like the digestive system.

Choice D reason:

Cortisol is released, increasing gluconeogenesis and reducing fluid loss. Cortisol, a key stress hormone, is released during long-term stress and increases gluconeogenesis, which is the production of glucose from non-carbohydrate sources. This helps maintain energy levels during prolonged stress. Cortisol also helps in reducing fluid loss by promoting sodium retention in the kidneys.

Choice E reason:

Immune system functioning decreases, and risk of cancer increases. Chronic stress can suppress the immune system, making the body more susceptible to infections and diseases. Prolonged immune suppression can also increase the risk of cancer as the body’s ability to detect and destroy abnormal cells is compromised.

Choice F reason:

Risk of depression, autoimmune disorders, and heart disease increases. Long-term stress is linked to an increased risk of depression and other mental health disorders due to the continuous release of stress hormones affecting brain function. It can also trigger autoimmune disorders by causing chronic inflammation and dysregulation of the immune system. Additionally, the persistent high levels of stress hormonees can lead to heart disease by promoting hypertension and other cardiovascular issues.

A. Talk to the client and identify the specific limits that are required of the client's behavior. B. Discuss the problem in a community meeting with the other clients on the unit present. C. Escort the client to her room each time the nurse observes the client socializing with other clients. D. Tell the other clients to ignore the client's lies.

Correct Answer is A

Explanation

Choice A reason:
Talking directly to the client and setting clear boundaries is a therapeutic approach. It respects the client's autonomy while also addressing the behavior that is affecting the therapeutic environment. By identifying specific limits, the nurse helps the client understand the consequences of their actions and the importance of maintaining a respectful and honest communication with others.

Choice B reason:
Discussing the problem in a community meeting could be helpful, but it should not be the initial action. This approach might inadvertently shame or embarrass the client in front of peers, which could exacerbate the situation. It's important to address the behavior privately before involving the larger group.

Choice C reason:
Escorting the client to their room each time they socialize could be seen as punitive and may not address the underlying reasons for the lying behavior. It could also isolate the client from social interactions that are an essential part of the healing process.

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A nurse is caring for a client on the Mental Health Unit. The client refuses to get out of bed, go to activities, or participate in any of the unit’s programs. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching about physiological responses to stress with a group of clients. The nurse should identify that which of the following changes reflect long-term physiological responses to stress? (Select all that apply)

Correct Answer is ["A","D","E","F"]

Explanation

A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain to the nursing staff about the client's disruptive behaviors. Which of the following initial actions should the nurse take?

Correct Answer is A

Explanation

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