A nurse is caring for a client who is depressed and refuses to participate in group therapy or perform activities of daily living. Which of the following statements should the nurse make to the client?

"The unit rules state that you may not remain in bed."

"You can remain in bed until you feel well enough to join the group."

"I will assist you in getting out of bed and getting dressed."

"If you don't participate in your care, you will not get better."

Answer and Explanation

The Correct Answer is C

Choice A reason:
This choice represents an authoritative approach, which may not be effective with a depressed client who is refusing therapy and ADLs. It does not offer support or understanding of the client's condition and may exacerbate feelings of helplessness or resistance to care.

Choice B reason:
While this statement offers a degree of autonomy to the client, it lacks the active encouragement and assistance that might be necessary to motivate a client who is depressed. It does not address the importance of participating in therapy or ADLs for the client's recovery.

Choice C reason:
This is the most therapeutic choice as it offers both support and a gentle nudge towards participation. It acknowledges the client's current state and provides a clear, immediate, and supportive next step. This approach can help reduce the client's feelings of being overwhelmed and can foster a sense of collaboration between the nurse and the client.

Choice D reason:
This statement, although factual, may come across as confrontational and could potentially discourage the client further. It does not provide the supportive framework that is crucial for engaging a client who is struggling with depression.

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

Explanation

Choice A reason:
Cirrhosis is a severe scarring of the liver and poor liver function seen at the terminal stages of chronic liver disease. It is one of the primary long-term effects of alcohol use disorder, as the liver is the main organ responsible for metabolizing alcohol. Chronic alcohol consumption can lead to inflammation, liver cell death, and eventually cirrhosis, which significantly impairs the liver's ability to function properly.

Choice B reason:
Heightened awareness is not typically a long-term physiological effect of alcohol use disorder. In fact, chronic alcohol use is more likely to dull cognitive functions and reduce awareness due to its depressive effects on the central nervous system.

Choice C reason:
Gastritis, an inflammation of the stomach lining, is another potential long-term effect of alcohol use disorder. Alcohol can irritate and erode the gastric mucosa, leading to gastritis, which may present with symptoms such as abdominal pain, nausea, and vomiting.

Choice D reason:
Brain damage is a serious long-term effect of alcohol use disorder. Alcohol can cause changes in the brain, leading to problems with cognition, memory, and motor skills. Chronic exposure to alcohol can result in brain shrinkage and the development of conditions like Wernicke-Korsakoff syndrome.

Choice E reason:
Esophageal varices are enlarged veins in the esophagus that can occur as a result of portal hypertension, often due to cirrhosis of the liver caused by alcohol use disorder. They are a significant risk because they can rupture and lead to life-threatening bleeding.

A. A: "I'm glad you called, and I want to send an ambulance to help you." B. B:"You must have been feeling pretty depressed to do that." C. C:"Were you trying to kill yourself by taking an overdose?" D. D:"Do you know how many pills were in the bottle?"

Correct Answer is A

Explanation

Choice A Reason:
In a situation where a client has ingested a potentially lethal amount of medication, immediate medical intervention is crucial. Amitriptyline is a tricyclic antidepressant, and overdose can lead to life-threatening conditions such as cardiac arrhythmias, severe hypotension, and seizures. The nurse's priority is to ensure the safety of the client by sending an ambulance. This response also acknowledges the client's cry for help and initiates prompt action.

Choice B Reason:
While it's important to recognize the emotional state of the client, this response does not address the immediate medical emergency. The client's safety is the priority, and while their feelings are valid, this choice does not facilitate the urgent care needed.

Choice C Reason:
Asking if the client was trying to commit suicide can come across as judgmental and may close off communication. It's essential to maintain an open line of communication and focus on getting medical help rather than determining intent at this critical moment.

Choice D Reason:
Knowing the quantity of medication ingested can be useful information for medical professionals; however, it is not the most immediate concern in a crisis situation. The first response should be to ensure that medical help is on its way.

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A nurse is caring for a client who is depressed and refuses to participate in group therapy or perform activities of daily living. Which of the following statements should the nurse make to the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a patient to the medical unit who has a history of alcohol use disorder. The nurse should be aware of which of the following potential long-term physiological effects on the patient's body? (Select all that apply)

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

Explanation

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Correct Answer is A

Explanation

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