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1. A. At 12 months, the child should be starting to walk. A hospitalization at this time could delay this developmental stage. The child should sit (4) by 6 months and should already be crawling (1) by 1 year of age.
2. D. Even though all of the reasons are important and should not be ignored, the most important task for the staff is to assess the client’s behavior and to identify cues that might indicate another impending suicide attempt.
3. B. One of the most important elements of trust is consistency. The client learns to trust that the nurse will follow through and do what is promised. Avoiding limit setting will not instill trust, nor will encouraging testing behaviors or telling the client how he should behave.
4. B. Hallucinations may involve any sense, and they have no basis in reality. The most common are auditory. Answer (3) is an example of an auditory hallucination. Answer (2) is an illusion; answer (4) is a delusion.
5. D. The client is placing blame on others and not taking responsibility for her own behavior. Reaction-formation is preventing “dangerous” feelings from being expressed by exaggerating the opposite attitude. Compensation is covering up a weakness by emphasizing a desirable trait. Acting out is not a defense mechanism.
6. D. The most important nursing attitude which underlies all interactions with this client, including a nurse-client relationship, would be to maintain a nonjudgmental approach. If a nurse carries any judgments about alcoholism, it will negate a working relationship with the client.
7. A. Depressed people often suffer from a sense of loss-loss of status, relationships, significant other, etc. While depression is more common in the middle to elderly age group, it is not necessarily related to stage of life (4). Neither poor interpersonal relationships (1) nor a traumatic childhood (2) is relevant as a cause of depression.
8. B. Concern with having a life-threatening disease is a common issue with depressed clients. While demanding behavior (3) may be a symptom, it is not the issue here. Whether or not the client is postmenopausal (1) is not relevant.
9. B. Because he may be trying to manipulate, it is important to end the interview at the agreed-upon time. Also, because the feelings are important, the nurse would need to encourage the client to bring them up again. Going over the agreed upon time (1) is nontherapeutic because it allows manipulation. Answers (2) and (3) are also nontherapeutic.
10. D. The nursing intervention is directed toward mobilizing the client without asking her to make a decision or trying to convince her to go. The nurse must be direct, specific, and not take no for an answer.
11. D. The immediate priority is to find the client and assess what further intervention may be needed. Whether or not the behavior has happened frequently in the past is irrelevant, because the behavior exhibited now is significant and should be followed up. Sending another client is inappropriate because an immediate intervention may be necessary.
12. D. The most important goal with a schizophrenic is to establish a trusting relationship, but not a warm, close one which would be too threatening (3). It is not a short-term goal to set limits on behavior or protect the client from deviant impulses-inappropriate behavior will diminish as medication takes hold and they become less disturbed (1).
13. B. This is a broad opening statement and the nurse is giving the client the opportunity to bring up the same topic or not. The nurse should not make the assumption that what was most important to the client yesterday is still most important today. Answer (2) has the nurse directing the focus, not the client. The other two responses are not as therapeutic as (3).
14. B. Giving the client a choice of how he would like to take his medication, while being firm that he must take it, gives the client a sense of control and helps to reduce the power struggle. Telling the client that the medication is not poison will do little to persuade him to comply. Answer (2) would represent a punishment. The client must take his medication; therefore, answer (4) is not appropriate.
15. A. The first intervention is to set firm, clear limits on his behavior. The nurse would also remain with the client until he calms down and then encourage him to discuss his feelings rather than act out.