The nurse is caring for a client diagnosed with Severe Intellectual Disability. Which of the following characteristics should the nurse recognize to be associated with Severe Intellectual Disability?

Other than possible coordination problems, the client's psychomotor skills are not affected.

The client communicates wants and needs by "acting out behaviors.”

The client can perform some self-care activities independently.

The client has advanced speech development.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Other than possible coordination problems, the client's psychomotor skills are not affected. Severe Intellectual Disability (ID) is characterized by significant limitations in intellectual functioning as well as adaptive behaviors. Coordination problems are not a primary characteristic of severe ID. The main focus is on cognitive and adaptive deficits.

Choice B rationale:

The client communicates wants and needs by "acting out behaviors." Severe ID can lead to challenges in effective communication. "Acting out behaviors" such as tantrums, aggression, or other disruptive actions might be the client's way of expressing themselves when they are unable to communicate verbally or effectively due to their cognitive limitations.

Choice C rationale:

The client can perform some self-care activities independently. Severe ID typically involves significant impairments in adaptive functioning, which includes self-care activities. The ability to perform some self-care activities independently is not consistent with the characteristics of severe ID.

Choice D rationale:

The client has advanced speech development. Severe ID is associated with delayed or impaired speech and language development. Advanced speech development would be contradictory to the diagnosis of severe ID, as this condition is characterized by substantial limitations in communication skills.

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Correct Answer is A

Explanation

Choice A rationale:

This statement requires intervention by the charge nurse. The nurse is making a judgmental suggestion to the client about how they should approach their marital issues. The nurse's role is to provide support, empathy, and open-ended questions that allow the client to explore their feelings and thoughts. Making a directive statement like this can be perceived as controlling and dismissive of the client's feelings.

Choice B rationale:

Relationship difficulties being stressful and requiring effort to resolve is an appropriate and empathetic response from the nurse. This acknowledges the client's struggles and offers validation without imposing a particular solution.

Choice C rationale:

Developing a plan for communication is a constructive approach that helps the client address their concerns. This response is within the nurse's scope of practice and promotes problem-solving and effective communication between partners.

Choice D rationale:

Encouraging the client to share more about their concerns regarding their marriage is a therapeutic response. It shows active listening and facilitates the client's exploration of their feelings, which is an essential aspect of the nursing role in a therapeutic relationship.

A. Supporting the client's wish to refuse prescribed medications. B. Encouraging client feedback about satisfaction with the facility experience. C. Making sure the client understands expectations for client participation. D. Explaining unit rules and policies regarding unacceptable behaviors.

Correct Answer is A

Explanation

Choice A rationale:

The ethical concept of autonomy centers on respecting an individual's right to make decisions about their own care, even if those decisions go against medical advice. By supporting the client's wish to refuse prescribed medications, the nurse is upholding the principle of autonomy. In mental health care, it is crucial to acknowledge and respect the client's right to make choices about their treatment, even if those choices might not align with the healthcare provider's recommendations. This action promotes patient empowerment and informed decision-making.

Choice B rationale:

While client feedback about satisfaction with the facility experience is important for quality improvement, it is not directly related to the ethical concept of autonomy. Autonomy pertains to the client's right to make decisions about their treatment and care, particularly when it comes to medical interventions and choices about their own body.

Choice C rationale:

Ensuring that the client understands expectations for client participation is more aligned with the principle of informed consent and effective communication rather than autonomy. While communication is important for respecting the client's autonomy, this choice does not directly demonstrate the core concept of allowing the client to make decisions about their treatment even if they differ from medical advice.

Choice D rationale:

Explaining unit rules and policies regarding unacceptable behaviors is related to maintaining a safe and structured environment within the psychiatric unit, but it does not directly reflect the ethical concept of autonomy. Autonomy pertains to decisions specifically related to the client's medical treatment and care, not just the rules of the unit.

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The nurse is caring for a client diagnosed with Severe Intellectual Disability. Which of the following characteristics should the nurse recognize to be associated with Severe Intellectual Disability?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is sharing information regarding concerns about their marriage. The client states "My spouse and I argue most times." Which of the following statements by the nurse requires intervention by the charge nurse?

Correct Answer is A

Explanation

A nurse is caring for a client diagnosed with a mental illness on a psychiatric unit. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?

Correct Answer is A

Explanation

A nurse notices that a client who has moderate anxiety is pacing the corridor and rambling. As the nurse approaches, the client states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?

A nurse is caring for a client who lost all his possessions in a house fire and states, "I have no idea what I am going to do. I cannot think right now." Which of the following actions should the nurse take?

A nurse in an acute care mental health facility is assessing a client who has bipolar disorder. The nurse recognizes that which of the following findings indicates the client is at risk for suicide?

A nurse is interviewing a client during admission to an alcohol treatment center. Which of the following approaches should the nurse take?

A nurse is caring for a client who is experiencing a manic episode. Other clients begin to complain about her disruptive behavior on the unit. Which of the following actions should the nurse take?

A nurse is caring for a client who has paranoid personality disorder. Which of the following findings should the nurse expect? (Select all that apply.).

A nurse is caring for a client who has bipolar disorder. Which of the following actions by the client should the nurse interpret as displaying manic behavior? (Select all that apply.).

A nurse is admitting an older adult client to the unit who has a suspected cognitive disorder. Which of the following inventories should be included as part of the admission assessment?