A nurse is assessing a client who is sharing information regarding concerns about their marriage. The client states "My spouse and I argue most times." Which of the following statements by the nurse requires intervention by the charge nurse?

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

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

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

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

Answer and Explanation

The Correct Answer is A

Choice A rationale:

This statement requires intervention by the charge nurse. The nurse is making a judgmental suggestion to the client about how they should approach their marital issues. The nurse's role is to provide support, empathy, and open-ended questions that allow the client to explore their feelings and thoughts. Making a directive statement like this can be perceived as controlling and dismissive of the client's feelings.

Choice B rationale:

Relationship difficulties being stressful and requiring effort to resolve is an appropriate and empathetic response from the nurse. This acknowledges the client's struggles and offers validation without imposing a particular solution.

Choice C rationale:

Developing a plan for communication is a constructive approach that helps the client address their concerns. This response is within the nurse's scope of practice and promotes problem-solving and effective communication between partners.

Choice D rationale:

Encouraging the client to share more about their concerns regarding their marriage is a therapeutic response. It shows active listening and facilitates the client's exploration of their feelings, which is an essential aspect of the nursing role in a therapeutic relationship.

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Correct Answer is D

Explanation

Choice A rationale:

"This is supposed to happen when you get old, right?" is a common misconception but doesn't necessarily support the diagnosis of delirium. It could be attributed to normal aging changes.

Choice B rationale:

"Since his mother died, he has not been feeling well." indicates a potential stressor but doesn't directly address the rapid onset of behavioral changes, which is a hallmark of delirium.

Choice C rationale:

"My husband just didn't seem to know what he was doing. He has been forgetful for years." suggests a history of forgetfulness rather than an acute change in behavior, which is more indicative of chronic cognitive issues like dementia.

Choice D rationale:

(Correct) "The changes in his behavior came on so quickly! I wasn't sure what was happening." This statement supports the diagnosis of delirium, which is characterized by a sudden onset of confusion and changes in cognitive function. Delirium often develops rapidly, and the client's wife's observation aligns with this diagnostic criterion.

A. Death of client's father two months ago. B. Adheres strictly to routines. C. Suspended from school several times in the past year. D. Experiences frequent facial tics.

Correct Answer is C

Explanation

The correct answer is choice C. Suspended from school several times in the past year.

Choice A rationale:

The client's father's recent death (Choice A) is not a typical expected assessment finding of conduct disorder. While emotional disturbances can be associated with conduct disorder, the primary characteristics involve behavioral issues rather than reactions to significant life events.

Choice B rationale:

Adhering strictly to routines (Choice B) is not a common expected assessment finding of conduct disorder. Conduct disorder is characterized by patterns of defiant and disruptive behaviors, not necessarily a rigid adherence to routines.

Choice C rationale:

Suspended from school several times in the past year (Choice C) aligns with the expected assessment findings of conduct disorder. Conduct disorder often involves aggressive behavior towards others, violation of rules, and disregard for the rights of others, which can lead to disciplinary actions such as school suspensions.

Choice D rationale:

Experiencing frequent facial tics (Choice D) is not a typical expected assessment finding of conduct disorder. Facial tics are associated with conditions like Tourette's syndrome or other tic disorders, not conduct disorder.

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A nurse is assessing a client who is sharing information regarding concerns about their marriage. The client states "My spouse and I argue most times." Which of the following statements by the nurse requires intervention by the charge nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A male client is admitted to the unit with a possible diagnosis of delirium. Which statement by the client's wife best supports the diagnosis?

Correct Answer is D

Explanation

A nurse is reviewing the history and physical of an adolescent client diagnosed with conduct disorder. The nurse recognizes that which of the following is an expected assessment finding of conduct disorder?

Correct Answer is C

Explanation

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