Which of the following statements by the nurse requires intervention by the charge nurse when a client is sharing concerns about their marriage?

"You should try to see your partner's point of view before your own."

"Tell me more about the concerns that you have regarding your marriage."

"We could develop a plan for how to talk about this with your partner."

"Relationship difficulties are stressful and require effort to resolve."

Answer and Explanation

The Correct Answer is A

Choice A reason:

This statement may require intervention by the charge nurse because it suggests the nurse is taking a directive approach, potentially overstepping professional boundaries. It implies that the client's perspective is less important than their partner's, which could undermine the therapeutic relationship and the client's sense of autonomy.

Choice B reason:

Asking the client to elaborate on their concerns is a therapeutic communication technique that encourages expression and exploration of feelings. It does not require intervention as it is supportive and facilitates the nurse-client relationship.

Choice C reason:

Offering to help the client develop a plan to discuss their concerns with their partner is a constructive approach that empowers the client. It promotes problem-solving and does not necessitate intervention by the charge nurse.

Choice D reason:

Acknowledging that relationship difficulties are stressful and require effort to resolve is an empathetic statement that validates the client's experience. It is supportive and does not require intervention.

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Correct Answer is D

Explanation

Choice A Reason:

Clients with severe intellectual disability typically require significant assistance with daily living activities. While they may be able to perform some basic self-care tasks with supervision, their ability to function independently is limited. They often need help with tasks such as dressing, bathing, and eating.

Choice B Reason:

Advanced speech development is not characteristic of severe intellectual disability. In fact, individuals with severe intellectual disability often have limited verbal communication skills. They may use single words, phrases, or gestures to communicate, and their speech development is generally delayed.

Choice C Reason:

Clients with severe intellectual disability often have psychomotor impairments. These can include difficulties with coordination, balance, and fine motor skills. Therefore, it is incorrect to state that their psychomotor skills are not affected.

Choice D Reason:

Communicating wants and needs by "acting out" behaviors is a common characteristic of severe intellectual disability. Due to limited verbal communication skills, individuals may express themselves through behaviors such as tantrums, aggression, or self-injury. These behaviors are often a way to communicate frustration, discomfort, or unmet needs.

A. Weigh the client every 3 to 4 days. B. Discourage the client from taking a nap during the day. C. Monitor vital signs throughout the day. D. Offer nutritional foods to the client every 2 hours. E. Maintain an environment with low stimuli.

Correct Answer is ["B","C","D","E"]

Explanation

Choice A Reason:

Weighing the client every 3 to 4 days is not typically a priority intervention for managing acute mania. While it's important to monitor for significant weight changes, the focus should be on more immediate concerns related to the manic state.

Choice B Reason:

Discouraging naps during the day can help regulate the client's sleep patterns. Sleep disturbances are common in mania, and establishing a routine that promotes adequate nighttime sleep is beneficial. It helps in reducing the hyperarousal state and stabilizing mood.

Choice C Reason:

Monitoring vital signs throughout the day is essential, as mania can lead to physical overactivity and increased metabolic demands. This can affect cardiovascular and thermoregulatory systems, necessitating close observation.

Choice D Reason:

Offering nutritional foods every 2 hours can help meet the increased metabolic demands during a manic episode. Clients may neglect nutrition due to hyperactivity or distractibility, so regular, balanced meals or snacks are important.

Choice E Reason:

Maintaining an environment with low stimuli is crucial in managing mania. Overstimulation can exacerbate symptoms such as restlessness, agitation, and distractibility. A calm environment helps in reducing sensory overload and can aid in the stabilization of the client's mood.

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Which of the following statements by the nurse requires intervention by the charge nurse when a client is sharing concerns about their marriage?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client diagnosed with severe intellectual disability. Which of the following characteristics should the nurse recognize to be associated with severe intellectual disability?

Correct Answer is D

Explanation

A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

A nurse is assessing a client who is withdrawing from alcohol. Which of the following findings should the nurse expect? (Select all that apply).

A nurse is providing teaching to a client who has an alcohol use disorder about Alcoholics Anonymous (AA). Which of the following client statements indicates an understanding of the program's basic concepts?

Which of the following approaches should the nurse take when interviewing a client during admission to an alcohol treatment center?

A nurse is planning care for a client newly admitted with major depressive disorder. After ensuring safety, which of the following actions should the nurse plan to take?

A nurse is performing an admission assessment on a client who has been diagnosed with schizophrenia. Which of the following findings should the nurse identify as a negative symptom?

A nurse notices that a client who has moderate anxiety is pacing the corridor and rambling. As the nurse approaches, the client states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?