A nurse is reviewing the day 5 vital signs and nurse’s notes.

Exhibits

A nurse is evaluating the client’s response to treatment. Select the 4 findings that indicate the client is progressing with their plan of care.

Client reports limiting alcohol consumption

Participation in group therapy

Appetite

Cognition

Vital signs

Movement through the stages of grief

Answer and Explanation

Correct Answer : B,C,D,E

Choice A: Client reports limiting alcohol consumption
While reporting a reduction in alcohol consumption is a positive sign, it is not as strong an indicator of progress as actual participation in structured treatment programs like group therapy. Self-reported data can sometimes be unreliable, especially in individuals with a history of substance use disorders.
Choice B: Participation in group therapy
Participation in group therapy is a significant indicator of progress. Group therapy provides a supportive environment where clients can share experiences, gain insights, and receive encouragement from peers. It also helps in building coping strategies and reducing feelings of isolation.
Choice C: Appetite
Improvement in appetite is a good indicator of physical recovery and overall well-being. Alcohol use disorder often leads to poor nutrition and weight loss, so an increase in appetite suggests that the client’s body is beginning to recover and that they are likely consuming more nutritious food.
Choice D: Cognition
Improved cognition indicates that the client is recovering from the neurological effects of alcohol intoxication. This includes better clarity of thought, improved memory, and the ability to respond coherently to questions. Cognitive recovery is crucial for the client to engage effectively in therapy and other treatment activities.
Choice E: Vital signs
Stabilized vital signs are a clear indicator of physical recovery. On admission, the client had a high blood
Choice F: Movement through the stages of grief
While moving through the stages of grief is important for emotional recovery, it is a more subjective measure and can vary greatly among individuals. It is not as directly measurable as the other indicators listed.

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Correct Answer is C

Explanation

Choice A reason:
Monitoring the client for splitting behaviors is important in managing paranoid personality disorder. Splitting is a defense mechanism where individuals cannot see others as having both positive and negative qualities; they are viewed as either all good or all bad. This behavior can disrupt therapeutic relationships and the treatment process. However, it is not the most constructive action to include in the plan of care.

Choice B reason:
Isolating the client from social or group interactions is not a therapeutic intervention and can be detrimental to the client's mental health. Social interactions can be challenging for individuals with paranoid personality disorder, but complete isolation is not recommended. Instead, the nurse should facilitate appropriate social interactions that do not overwhelm or trigger the client's paranoia.

Choice C reason:
Providing written information about the client's treatment plan can be very beneficial for individuals with paranoid personality disorder. It allows them to review the plan at their own pace and may help reduce feelings of suspicion or paranoia, as they have clear, documented information about their care.

Choice D reason:
Encouraging countertransference is not an appropriate action. Countertransference occurs when a healthcare provider transfers emotions to a client, often based on the provider's past experiences. This can interfere with objective care and is something to be aware of and managed, not encouraged.

A. "I will stay in bed on days when I feel exhausted." B. "I will use the coping mechanisms that helped me in the past." C. "I will avoid talking about events that upset me." D. "I will rely on my partner to plan out my schedule each day."

Correct Answer is B

Explanation

Choice A reason:
Staying in bed on days when feeling exhausted may seem like a reasonable self-care behavior, especially for someone with major depressive disorder. However, excessive bed rest can actually exacerbate depressive symptoms. It's important to balance rest with activities that promote a sense of accomplishment and well-being.

Choice B reason:
Using coping mechanisms that have been helpful in the past is a sign of understanding self-care teachings. It shows the client is applying learned strategies to manage their symptoms and is taking an active role in their own care. This proactive approach is encouraged in managing major depressive disorder.

Choice C reason:
While it may be necessary to avoid certain triggers, consistently avoiding talking about upsetting events can lead to suppression of emotions, which is not a healthy coping strategy. It's important for individuals with depression to express their feelings and work through their emotions.

Choice D reason:
Relying on a partner to plan out one's schedule every day can create dependency and reduce the sense of personal control and autonomy. While support from loved ones is valuable, the individual should be encouraged to take responsibility for their own schedule as part of their self-care routine.

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A nurse is reviewing the day 5 vital signs and nurse’s notes. Exhibits A nurse is evaluating the client’s response to treatment. Select the 4 findings that indicate the client is progressing with their plan of care.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a client who has paranoid personality disorder. Which of the following actions should the nurse include in the plan?

Correct Answer is C

Explanation

A nurse is providing teaching about self-care behaviors to a client who has major depressive disorder. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

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A nurse is reviewing the day 5 vital signs and nurse’s notes.

Exhibits

A nurse is evaluating the client’s response to treatment. Select the 4 findings that indicate the client is progressing with their plan of care.