A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment, the client tells the nurse that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the nurse to provide?

Unless your sister has a medical education, ignore her comments.

I can hear that your sister's comments are overwhelming you.

Do you think it is possible that you might be a hypochondriac?

Besides your sister's comments, what in your life is troubling you?

Answer and Explanation

The Correct Answer is D

Choice A rationale: Ignoring comments about the sister's lack of medical education may not address the client's feelings and concerns. It is essential to explore the client's emotions.

Choice B rationale: Acknowledging that the sister's comments are overwhelming is supportive but may not actively address the client's self-perception.

Choice C rationale: Asking if the client thinks she might be a hypochondriac could be interpreted as judgmental and may not promote an open discussion about the client's concerns.

Choice D rationale: Asking about what is troubling the client, besides her sister's comments, encourages the client to express her feelings and provides an opportunity for the nurse to understand the client's perspective and concerns.

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Correct Answer is C

Explanation

Choice A rationale: Individual addiction counseling may be beneficial for the client but does not address the immediate physiological issue of Wernicke encephalopathy. Thiamine replacement is the priority.

Choice B rationale: Initiating disulfiram teaching is not relevant to the management of Wernicke encephalopathy. Disulfiram is used for alcohol aversion therapy, not thiamine deficiency.

Choice C rationale: Thiamine administration is the most critical intervention for Wernicke encephalopathy caused by alcohol addiction. Thiamine deficiency is a key factor in the development of this condition.

Choice D rationale: Nutrition referral may be important for the client's overall well being, but it is not the priority when the client is experiencing Wernicke encephalopathy. Immediate thiamine replacement is essential.

A. An overdose of cocaine can be lethal. B. Addiction affects all aspects of one's life and one's family. C. Denial of an addiction problem is often the first response to the behavior. D. Mind altering drugs take away one's ability to make good decisions.

Correct Answer is D

Explanation

A. An overdose of cocaine can be lethal:
While this statement is accurate, it focuses on extreme outcomes rather than addressing the student's belief in their ability to control cocaine use. It may not encourage the student to reconsider their stance on trying the drug.

B. Addiction affects all aspects of one's life and one's family:
This response provides important information about the long-term consequences of addiction but does not directly counter the student's claim about their ability to control initial use. It may not be as impactful in the immediate context.

C. Denial of an addiction problem is often the first response to the behavior:
This response assumes the student is already using substances or experiencing addiction. It does not directly address the student's specific belief in their ability to control their actions after trying cocaine.

D. Mind-altering drugs take away one's ability to make good decisions:
This response is most appropriate because it directly challenges the student's confidence in their ability to control their behavior. It provides a logical explanation of why experimenting with cocaine is inherently risky, as it impairs judgment and decision-making, making it harder to "stop" as they claim

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Naxlex Comprehensive Predictor Exams

A client who experiences memory loss is diagnosed with Wernicke encephalopathy caused by alcohol addiction. Which intervention is most important for the nurse to implement?

Correct Answer is C

Explanation

During a high school class on substance abuse, a student tells the group, "If I tried cocaine, I know I could handle it. I know when to stop." Which response is best for the nurse to provide?

Correct Answer is D

Explanation

A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent when the client says, "I don't know how I will go on." What is the reason for the nurse's behavior?

A woman who attends a stress management group reveals to group members that though she recently divorced, she continues to care for her husband's aging parents. Which psychological mechanism should the nurse address in the plan of care?

A client who has been taking clozapine reports experiencing a sore throat and has a temperature of 101.9° F (38.8° C). Which action should the nurse take?

A college student is admitted to the mental health unit following a drug overdose. The student tells the nurse about the overdose following the end of a romantic relationship. Which is the primary goal for hospitalization that should be included in this client's plan of care?

During admission to the psychiatric unit, a client is extremely anxious and reports being worried about the sun coming up the next day. Which intervention is most important for the nurse to implement during the admission process?

An 18-year-old client is brought to the emergency department with a suspected drug overdose. Which information is most important for the nurse to obtain from the family?

A client with chronic alcoholism receives a prescription for disulfiram. Which client statement indicates that this medication teaching has been effective?