A nurse is leading a group therapy session for clients who are newly diagnosed with cancer. Which of the following statements should be an appropriate response by the nurse?

"You need to work hard on resolving conflict with those closest to you.”

"Let's discuss what you mean when you say that you cannot ever return to work.”

"I notice you keep clenching your fists. Why are you doing this?”

"Antidepressants are not your solution, but this therapy group is.”

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Telling the newly diagnosed cancer clients that they need to work hard on resolving conflicts with those closest to them may come across as insensitive and dismissive of their emotional struggles. Cancer diagnosis often brings about complex emotions, and this response does not acknowledge or address their concerns.

Choice B rationale:

This response acknowledges the client's statement and encourages further discussion about their feelings regarding their inability to return to work. It shows empathy and a willingness to explore their concerns, promoting open communication and emotional support.

Choice C rationale:

Commenting on the client's physical behavior without context might make them uncomfortable or self-conscious. The nurse's observation about fist clenching should be addressed more delicately if relevant, and the focus should be on the emotional aspect rather than the physical behavior.

Choice D rationale:

Dismissing the potential benefit of antidepressants and promoting the therapy group might undermine the client's feelings and choices. While group therapy can be beneficial, this response overlooks the potential need for a multifaceted approach to treatment, which could include therapy and medication.

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Correct Answer is C

Explanation

Answer: c. Document the client's verbatim statements.

Here's why the other options are wrong:

a. Ask the client for permission to take photographs:While photographs may be collected as evidence later, it should not be the first priority. The priority is to focus on patient care and emotional well-being.
b. Provide community sexual assault support contacts:Offering support resources is important, but documenting the details of the assault is crucial for forensic and legal purposes, and should come first.
d. Determine any physical signs of injury:Looking for physical injuries is important, but documenting the client's account should come first. This ensures the client's narrative is captured accurately and can be referred to later.

Documenting the client's verbatim statements is the most important initial action because:

It preserves the client's account of the assault in their own words.
It allows for accurate reporting and investigation.
It can be used as evidence in legal proceedings.

Here are some supporting points:

The Rape, Abuse & Incest National Network (RAINN):"Law enforcement will need to take a detailed statement about the assault, and a medical professional will likely perform a physical exam. Be prepared to answer questions about what happened." [1]
The National Sexual Assault Hotline:"Law enforcement will want to get a statement from you as soon as possible after the assault. Try to remember the details of the assault as clearly as you can." [2]

In conclusion, while all the other options are important aspects of caring for a sexual assault survivor, documenting the client's verbatim statements is the most critical initial action for a nurse to take in the emergency department setting.

A. "You may experience dizziness upon standing while taking this medication.” B. "This medication will decrease your symptoms of OCD.” C. "You can stop taking the medication if the side effects are bothersome.” D. "This medication may cause excessive salivation.”

Correct Answer is A

Explanation

The correct answer is choice A: "You may experience dizziness upon standing while taking this medication."

Choice A rationale:

This choice is the correct answer because haloperidol, an antipsychotic medication, can cause orthostatic hypotension, which leads to dizziness upon standing. Antipsychotic medications often affect blood pressure regulation and can result in a sudden drop in blood pressure when transitioning from sitting or lying down to standing. This explanation provides essential information to the client to help them understand potential side effects and take necessary precautions.

Choice B rationale:

This choice is incorrect. Haloperidol is not indicated for treating symptoms of obsessive-compulsive disorder (OCD). It is primarily used to manage symptoms of schizophrenia and other psychotic disorders. Providing false information about its indications is not appropriate and may lead to confusion.

Choice C rationale:

This choice is incorrect. Clients should never stop taking antipsychotic medications abruptly without consulting their healthcare provider. Discontinuing such medications can lead to withdrawal effects and a worsening of symptoms. Encouraging the client to stop the medication if side effects are bothersome is not appropriate and could potentially jeopardize their well-being.

Choice D rationale:

This choice is partially correct but not the best answer. While haloperidol can cause excessive salivation (sialorrhea) as a side effect, the primary concern in this situation should be related to orthostatic hypotension and dizziness upon standing. Mentioning excessive salivation would be helpful, but it's secondary to the risk of falls associated with orthostatic hypotension.

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A nurse is leading a group therapy session for clients who are newly diagnosed with cancer. Which of the following statements should be an appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is performing an assessment on a client who reports being sexually assaulted. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is providing teaching to a client diagnosed with schizophrenia and is prescribed haloperidol (Haldol). Which of the following information should the nurse include in the teaching?

Correct Answer is A

Explanation

A psychiatric nurse is caring for clients on a mental health unit during a group session. What should the nurse do to establish trust in a therapeutic relationship with the clients?

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?

A nurse is talking with a client diagnosed with schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the following should be the appropriate action by the nurse?

A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect?

A nurse is teaching a newly licensed nurse about reporting suspected child abuse. Which of the following statements indicates that the newly licensed nurse has the correct information about child abuse?

A nurse is assessing an adolescent female client who has anorexia nervosa. Which of the following findings should the nurse expect?

The nurse is asking a diagnosed schizophrenic patient how they slept and they respond, "This is a new day in May and I can't wait to play." Which communication pattern does the nurse identify?