A female client who is a retired school teacher is admitted for a breast biopsy. After being told that the biopsy was positive for cancer, she becomes dependent and asks her family for help with activities of daily living that she is physically capable of performing. Which interpretation of this client's behavior by the nurse is likely to be most accurate?

Expected, as the client is attempting to reduce anxiety by regressing to a state of lesser anxiety.

Should be encouraged as representative of the client's non-destructive method of fear expression.

Unacceptable, and limits should be set to encourage the client to maintain her independence.

Should be accepted by staff as the first step the client must experience in the grieving process.

Answer and Explanation

The Correct Answer is A

A.   This behavior can be seen as a regression aimed at reducing anxiety during a stressful time, which is a relatively common psychological response to stress or trauma.
B.   While it may be a way for the client to cope, encouraging dependency might not necessarily be the best approach to fostering independence.
C.   While independence is important, setting rigid limits might not address the underlying emotional needs during a period of distress.
D.   Acknowledging and understanding the client's behavior as a coping mechanism within the grieving process can help the staff provide appropriate support and care.

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Correct Answer is D

Explanation

A. Developing a list of pleasurable activities might be beneficial but might not directly address the lack of motivation and psychomotor retardation.
B. Encouraging exercise is generally helpful but might be challenging for someone experiencing hypersomnia and lack of motivation.
C. Providing education on methods to enhance sleep is important, but it might not directly address psychomotor retardation or motivation.
D. Teaching the client to develop a plan for daily structured activities can provide a sense of purpose, routine, and help combat psychomotor retardation and lack of motivation commonly seen in depression.

A. Both the nurse and therapist are reprimanded for divulging confidential patient information to others. B. The nurse and therapist will be asked to educate other team members on appropriate sharing of client information. C. The nurse is reprimanded for divulging confidential patient information without obtaining informed consent. D. The therapist is reprimanded for divulging confidential patient information without obtaining consent.

Correct Answer is B

Explanation

A. Both the nurse and therapist took action to ensure safety; therefore, reprimanding might not be appropriate.
B. The best outcome is an educational approach for the team to understand appropriate information sharing in cases of potential harm to others while maintaining patient confidentiality.
C. The nurse's immediate notification was based on safety concerns, which may take precedence over obtaining informed consent.
D. The therapist's action aimed at ensuring safety but might have breached confidentiality without explicit consent.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and lack of motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

A female college student is admitted to the mental health unit following a drug overdose. The student tells the nurse that she took 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?

The nurse is assessing a client who reports using cocaine several times in the past week.Which observations should the nurse expect on assessment?

An antidepressant medication is prescribed for a client who reports sleeping only four hours in the past two days and a weight loss of nine pounds within the last month. Which client goal is most important to achieve within the first three days of treatment?

A client with borderline personality disorder tells the nurse, "You are the best nurse on the unit! The other nurses don't care about me the way you do." Which response should the nurse provide to this client?

A client with a history of alcoholism is admitted for detoxification. Based on treatment protocol, the nurse gives the client a dose of lorazepam 6 mg. Which additional prescription should the nurse administer immediately?

The nurse is assessing a client whose spouse died of a stroke two weeks ago and who reports having numbness and tingling on the right side of the body. The nurse should consider the client's symptoms may likely be due to which condition?

Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?