A young adult female client is admitted to the emergency department after being raped in a shopping center parking lot. The client expresses no suicidal ideation, but expresses feelings of self-blame for not taking precautions when going to her car. According to theorists, such as Maslow and Erikson, this client is struggling with which issue?

Self-control.

Self-actualization.

Self-esteem.

Self-absorption.

Answer and Explanation

The Correct Answer is C

Choice A rationale: Self-control is not the primary issue identified in this scenario. The client's self-blame may be related to other factors.

Choice B rationale: Self-actualization is not the primary issue in this scenario. The client is dealing with feelings of self-blame and potential guilt.

Choice C rationale: Self-esteem is the most relevant issue in this scenario. The client expresses feelings of self-blame, indicating a potential impact on self-esteem. Addressing self-esteem is crucial for the client's emotional well-being.

Choice D rationale: Self-absorption is not the primary issue in this scenario. The client's focus on self-blame and guilt is related to self-esteem concerns.

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Correct Answer is C

Explanation

Choice A rationale: Remaining silent does not necessarily indicate disapproval; it is a therapeutic communication technique to allow the client to express feelings without interruption.

Choice B rationale: While the client may be experiencing sadness, the nurse's silence is not reflecting the client's emotions but rather providing space for the client to express their thoughts and feelings.

Choice C rationale: Silence, in this context, is therapeutic because it allows the client time and space to reflect on and explore their own thoughts and feelings. It promotes self-discovery and expression.

Choice D rationale: Respecting the client's loss is a general principle, but the specific therapeutic use of silence in this situation is to allow the client to process and express their emotions.

A. Recommend that the client talk with a social worker today. B. Offer the client a safe place to relax before the Interview. C. Assure client of an interview with the healthcare provider today. D. Ask the client to describe the stalker and If It is frequent.

Correct Answer is B

Explanation

Choice A Rationale: While talking to a social worker could be beneficial, it may not address the client's immediate need for safety and comfort. Social work intervention is important, but the priority is to ensure the client feels secure in the current environment.
Choice B Rationale: Offering a safe place to relax is crucial as it addresses the client's immediate need for safety and security. Feeling safe can help reduce anxiety and allows the client to compose themselves before discussing their concerns in detail.
Choice C Rationale: Assuring an interview with the healthcare provider is important, but it does not prioritize the client's immediate emotional and psychological needs. The assurance of care is part of the overall treatment plan but is secondary to providing a safe environment.
Choice D Rationale: Asking the client to describe the stalker is part of the assessment process, but it is not the most important initial action. The client's immediate emotional state must be stabilized before any detailed information gathering can be effective.

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Naxlex Comprehensive Predictor Exams

A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent when the client says, "I don't know how I will go on." What is the reason for the nurse's behavior?

Correct Answer is C

Explanation

A client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because of a stalker. Which action is most important for the nurse to take?

Correct Answer is B

Explanation

The nurse is providing teaching to a client and family about schizophrenia before discharge from an inpatient facility. The nurse should instruct the family to notify the healthcare provider when which behavior is observed?

The nurse is completing an admission assessment for a client with a known history of depression and multiple, unexplained fractures. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)?

The nurse interacts with a client who is very depressed and slow to respond to questions. The nurse asks the client to describe current feelings, but the client looks down at the table. Which action is best for the nurse to implement?

An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam. During the health assessment, the client reports experiencing of chest pain. Which action should the nurse take first?

A middle-aged female client with no previous psychiatric history is seen in the mental health clinic because her family describes her as having paranoid thoughts. On assessment, she tells the nurse, "I want to find out why these people are stalking me!" Which response should the nurse provide?

A client is admitted to the emergency department because of a possible overdose of methadone and benzodiazepines. The admission respiratory rate is 6 breaths/minute. Based on this finding, the nurse should prepare for which intervention?

A client who is experiencing a severe level of anxiety and reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?

A college student is admitted to the mental health unit following a drug overdose. The student tells the nurse about the overdose following the end of a romantic relationship. Which is the primary goal for hospitalization that should be included in this client's plan of care?