A nurse is discussing mental health with a client. Which of the following statements by the client requires follow-up by the nurse?

"My boss often asks me to work overtime, but I have to refuse the extra hours due to my responsibilities at home."

"The demands of raising two young children by myself are often overwhelming, and I sometimes need some alone time to recharge."

"On the weekends when my kids are with their other parent, I often just lay in bed all day and cry, because I feel hopeless."

"Work can be extremely stressful at times, so I often need to take a walk during my lunch break."

Answer and Explanation

The Correct Answer is C

Rationale:

A. This statement reflects a healthy boundary-setting behavior, where the client recognizes their limits and makes decisions accordingly.

B. This reflects a healthy coping mechanism, where the client acknowledges their stress and takes time to recharge, which is important for mental health.

C. This statement indicates a possible depressive symptom, as feeling hopeless and withdrawing from activities (like staying in bed and crying) can be signs of depression. This requires follow-up to assess the client's mental health and provide appropriate support.

D. Taking a walk during stressful times is a positive coping strategy that helps manage stress and maintain mental health.

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Correct Answer is B

Explanation

Rationale:

A. Boundaries refer to maintaining professional limits in the nurse-client relationship, which is not directly related to the cause of hallucination exacerbation.

B. Relapse is the return of symptoms after a period of improvement, which is a common explanation for the recurrence of hallucinations in a client with schizophrenia.

C. The SE model (Social Ecological Model) is a framework for understanding the various levels of influence on health behaviors and is not a direct cause of hallucinations.

D. Stigma refers to the negative attitudes and beliefs about mental illness, which can affect a client’s self-perception but is not a direct cause of symptom exacerbation.

A. The final 2 min B. The final 15 min C. The first 15 min D. The first 2 min

Correct Answer is C

Explanation

Rationale:

A. Observing the final 2 minutes is not sufficient for detecting acute transfusion reactions, which can occur at any time during the transfusion.

B. Observing the final 15 minutes is also not adequate; reactions can occur earlier.

C. The first 15 minutes is the most critical time for observing for transfusion reactions, as most reactions occur during this period.

D. The first 2 minutes are too brief to detect potential transfusion reactions, which typically manifest within the first 15 minutes.

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A nurse is discussing mental health with a client. Which of the following statements by the client requires follow-up by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has schizophrenia with an exacerbation of hallucinations. The client states, "I do not understand why the hallucinations have come back." The nurse should explain that which of the following is the reason for the exacerbation of hallucinations?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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