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 B

Explanation

A. Role-playing might not be suitable for a hyperactive 4-year-old with potential autism, as their attention span and ability to engage in structured activities might be limited.
B. Adolescents often benefit from role-playing to navigate social situations and address feelings of rejection or lack of acceptance from peers.
C. Role-playing might not be as effective for an older adult in a long-term care facility who takes others' belongings, as this behavior may require different interventions.
D. While role-playing can be helpful for individuals with schizophrenia, their tendency to refuse medications might not necessarily be addressed through this method.

A. I do care about you as a person but nothing more. B. I am not the best nurse. All the nurses are good. C. The other nurses and I are here to help you get better. D. You don't think the other nurses care about you?

Correct Answer is C

Explanation

A. This response may invalidate the client's feelings and might not provide reassurance about the nurse's support.
B. This response deflects the client's statement and might not address the client's feelings of being cared for.
C. This response acknowledges the client's feelings, reinforces the presence of the nursing team, and emphasizes the collective goal of helping the client get better.
D. This response might indirectly question the client's perception and doesn't directly address the client's need for reassurance and support.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse plans to use role-playing as a therapeutic measure. Which individual is most likely to benefit from this type of therapeutic intervention?

Correct Answer is B

Explanation

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?

Correct Answer is C

Explanation

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?

A client who is an alcoholic receives a prescription for disulfiram 500 mg by mouth (PO) daily. Which instruction should the nurse provide to this client?

The nurse is planning the care for a client who is hospitalized with bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? (Select all that apply.)

A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?

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?

When responding to a call light, the nurse finds a client with aggressive behaviors pacing and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease-related?