A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

Concentrate on and ventilate emotions when distressed.

Relax and reduce the amount of effort to solve the problem.

Shift attention from self to the needs and requests of others.

Focus on small achievable tasks, not taxing problems.

Answer and Explanation

The Correct Answer is D

A.   Ventilating emotions when distressed may be helpful in some situations, but it may not directly address the client's avoidance behavior or assist in building coping skills to manage responsibilities.
B.   Relaxing and reducing effort to solve problems may exacerbate feelings of helplessness and avoidance, rather than promoting active coping strategies.
C.   Shifting attention from self to the needs and requests of others may be beneficial in certain contexts, but it may not directly address the client's depressive symptoms or avoidance behavior.
D.   Focusing on small achievable tasks allows the client to experience a sense of accomplishment and mastery, which can help counteract feelings of helplessness and build confidence in managing responsibilities. This approach aligns with behavioral activation techniques commonly used in the treatment of depression.

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Correct Answer is B

Explanation

- Choice A Rationale: Determining the type and size of the locks does not address the client's anxiety or the behavior that is impacting their daily functioning. This action might inadvertently reinforce the client's focus on the locks rather than addressing the underlying issue.
- Choice B Rationale: Planning a list of activities to be carried out daily can help the client establish a routine, which may reduce anxiety and the need for repetitive checking. This approach encourages the client to focus on the day's tasks and can provide a sense of control and accomplishment.
- Choice C Rationale: Discussing checking the time frequently does not directly address the client's repetitive behavior or the associated anxiety. While time management may be part of a broader treatment plan, it is not the most immediate action the nurse should take.
- Choice D Rationale: Ask the client why the locks are checked so frequently is not therapeutic and may put the client on the defensive. Clients with obsessive-compulsive behaviors often cannot explain why they perform rituals, as the behavior is driven by anxiety rather than logic. Asking "why" may increase frustration without helping to address the behavior.

A. Client claims that she was forced to participate in sexual intercourse. B. Client reported that she had sexual relations against her will. C. Client has been sexually assaulted. D. Client states, "My date raped me tonight."

Correct Answer is D

Explanation

Rationale for A: The phrase "Client claims" may imply doubt or a lack of belief in the client's account. It's important to use non-judgmental language that reflects the client's words without interpretation or bias. This choice is less appropriate because it doesn't use the client's exact words.

Rationale for B: This statement generalizes the situation and lacks the specificity of the client’s actual words. It may not capture the emotional impact or the client's clear identification of the event as rape. Direct quotations are preferred for documenting sensitive situations like this.

Rationale for C: While "Client has been sexually assaulted" is accurate, it is a general term. It is preferable to document the client's own words verbatim in the medical record to ensure clarity and to avoid any misinterpretation or assumptions.

Rationale for D: Documenting the client's exact words ("My date raped me tonight") ensures that the medical record accurately reflects the client's experience without interpretation. It is crucial to use the client's own language when documenting incidents of sexual assault.

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A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client engages in repeated checks of door and window locks and behavior that prevents the client from arriving on time and interfering with the ability to function effectively. Which action should the nurse take?

Correct Answer is B

Explanation

A young female client is admitted to the emergency room because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record as the client's chief complaint?

Correct Answer is D

Explanation

The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessment?

The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in depth with the client based on this screening tool?

Which individual should the nurse consider at highest risk for suicide?

A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?

The nurse is caring for a client Exhibits In order to help the client disclose a situation that is upsetting to him, what therapeutic communication tools could the nurse use? Select all that apply.

An adult female client is brought to the Emergency Center after fainting at work. The nurse completes an assessment of the client and identifies caregiver role strain as a nursing problem. Which information best supports this problem?