A nurse is caring for a client who was admitted to the facility in critical condition following a cerebrovascular accident.

The client's son says to the nurse, "I wish I could stay, but I need to go home to see how my children are doing. I really hate to leave." Which of the following responses should the nurse make?

"There's nothing you can do here. You should go home to your children."

"You are feeling drawn in two separate directions."

"Perhaps you could call your children to see how they are doing."

"Don't worry.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Dismissive and unsupportive: This response discounts the client's son's feelings of guilt and obligation toward their parent. It also implies that the client's son's presence is not valuable, which could further increase their distress.

Undermines the client's son's role as a caregiver: It suggests that the client's son has no responsibilities or ability to contribute to their parent's care, which could diminish their sense of agency and potentially lead to resentment or regret.

Fails to address the underlying emotions: It does not acknowledge the client's son's internal conflict and emotional turmoil, which is essential for providing effective support.

Choice C rationale:

Offers a practical solution, but may not address the core issue: While calling the children could provide temporary reassurance, it may not fully alleviate the client's son's feelings of guilt or anxiety about leaving their parent.

May not be feasible or sufficient: The client's son may need more than a phone call to feel comfortable leaving, and they may not be able to reach their children immediately.

Could be perceived as dismissive: It could suggest that the nurse is minimizing the client's son's concerns and not fully understanding their emotional needs.

Choice D rationale:

Reassuring, but may not address the client's son's guilt: While it provides assurance about the client's care, it does not directly acknowledge or validate the client's son's feelings of guilt or obligation.

Focuses on the client's care, but not the client's son's needs: It prioritizes the physical care of the client, but may overlook the emotional needs of the client's son, who is also a primary stakeholder in the situation.

May not be enough to alleviate the client's son's concerns: The client's son may still feel responsible for their parent's well- being, even with reassurance from the nurse.

Choice B rationale:

Empathetic and validates the client's son's feelings: It directly acknowledges the client's son's conflicting emotions and demonstrates understanding of their difficult situation.

Promotes self-reflection and exploration: It encourages the client's son to further express their feelings and explore their options, which can lead to greater clarity and self-awareness.

Facilitates decision-making: It helps the client's son to weigh their priorities and make a decision that aligns with their values and responsibilities, ultimately empowering them to take action.

Strengthens the therapeutic relationship: It demonstrates the nurse's ability to connect with the client's son on an emotional level, building trust and rapport.

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Correct Answer is D

Explanation

Choice A rationale:

Repression: This statement suggests that the client is unconsciously blocking out memories of the tragedy as a way to cope with the anxiety. While repression can be a defense mechanism, it's not considered an adaptive use of sublimation.

Sublimation involves channeling anxiety into a productive or socially acceptable activity.

Denial of anxiety: The client's denial of anxiety, despite outward signs of distress, indicates a lack of awareness or acceptance of their emotional state. This can hinder effective coping and processing of the trauma.

Potential for delayed or prolonged distress: Repressed memories can resurface later, often in unexpected or disruptive ways, potentially leading to prolonged or intensified distress.

Choice B rationale:

Hopelessness and helplessness: The client's statement reflects a sense of defeat and a belief that they are incapable of overcoming the trauma. This can lead to feelings of despair, isolation, and withdrawal.

Lack of adaptive coping mechanisms: The client's inability to envision a future beyond the tragedy suggests a lack of healthy coping strategies to manage their anxiety and move forward.

Risk of prolonged distress and potential for depression: Persistent feelings of hopelessness and helplessness can increase the risk of developing depression or other mental health conditions.

Choice C rationale:

Denial of anxiety and potential lack of insight: The client's denial of anxiety, despite the nurse's observation, suggests a lack of awareness or acceptance of their emotional state. This can impede effective coping and processing of the trauma.

Potential resistance to support: The client's defensiveness may make it challenging for them to receive support or engage in therapeutic interventions.

Risk of delayed or unmanaged distress: If the client continues to deny their anxiety, they may not seek appropriate help, potentially leading to prolonged or intensified distress.

Choice D rationale:

Sublimation: This statement demonstrates the client's ability to channel their anxiety into a constructive and healthy outlet. Physical activity can provide a release for pent-up emotions, reduce stress, and improve overall well-being.

Adaptive coping mechanism: The client's choice to engage in physical activity as a way to manage their emotions indicates a positive coping strategy that can promote resilience and recovery.

Potential for improved mental and physical health: Regular exercise has numerous benefits for both mental and physical health, which can support the client's overall well-being and recovery process.

A. 1 tablet B. 2 tablets C. 3 tablets D. 4 tablets.

Correct Answer is A

Explanation

Step 1: The total daily dose of quetiapine is 50 mg, divided equally every 12 hours. So, each dose is 50 mg ÷ 2 = 25 mg.

Step 2: The available quetiapine tablets are 25 mg each. So, to administer a 25 mg dose, the nurse would need 25 mg ÷ 25 mg/tablet = 1 tablet.

Therefore, the nurse should administer1 tablet

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who appears anxious following a recent tragedy.Which of the following statements by the client reflects an adaptive use of sublimation?

Correct Answer is D

Explanation

A provider prescribes quetiapine 50 mg PO divided equally every 12 hr for 3 days. Available is quetiapine 25 mg tablets. How many tablets should the nurse administer per dose on day 3? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is A

Explanation

A mental health nurse on an inpatient eating disorders unit is caring for a client who has anorexia nervosa and has a body mass index of 16.7. Which of the following actions should the nurse take? (Select all that apply.)

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