HESI Computerized Adaptive Testing (CAT) Test Bank

the nurse explain is the main reason for drinking alcohol in people with a long history of alcohol abuse? 1 They are dependent on it. 2 They lack the motivation to stop. 3 They use it for coping. 4 They enjoy the as ...

the nurse explain is the main reason for drinking alcohol in people with a long history of alcohol abuse? 1 They are dependent on it. 2 They lack the motivation to stop. 3 They use it for coping. 4 They enjoy the associated socialization. ✓ Ans- 1 Alcohol causes both physical and psychological dependence; the individual needs the alcohol to function. Alcoholism is a disorder that entails physical and psychological dependence. Because alcohol is so physiologically addictive, the client's body craves the alcohol, so most clients lack the motivation to stop because they will go into withdrawal. Clients who abuse alcohol have numbed their ability to utilize other coping mechanisms, so alcohol is used as an excuse for coping. People with alcoholism usually drink alone or feel alone in a crowd; socialization is not the prime reason for their drinking. How do adolescents establish family identity during psychosocial development? Select all that apply. 1 By acting independently to make his or her own decisions 2 By evaluating his or her own health with a feeling of well-being 3 By fostering his or her own development within a balanced family structure 4 By building close peer relationships to achieve acceptance in the society 5 By achieving marked physical changes ✓ Ans- 1,3 An adolescent establishes family identity by acting independently for taking important decisions about self. They also need to foster their development along with maintaining a balanced family structure. Health identity is associated with the evaluation of one's own health with a feeling of well-being. By building close peer relationships, an adolescent develops a sense of belonging, approval, and the opportunity to learn acceptable behavior. These actions establish an adolescent's group identity. The sound and healthy growth of the adolescent, with marked physical changes, helps to build an adolescent's sexual identity. A clinic nurse observes a 2-year-old client sitting alone, rocking and staring at a small, shiny top that she is spinning. Later the father relates his concerns, stating, "She pushes me away. She doesn't speak, and she only shows feelings when I take her top away. Is it something I've done?" What is the most therapeutic initial response by the nurse? 1 Asking the father about his relationship with his wife 2 Asking the father how he held the child when she was an infant 3.Telling the father that it is nothing he has done and sharing the nurse's observations of the child 4 Telling the father not to be concerned and stressing that the child will outgrow this developmental phase ✓ Ans- 3 The nurse provides support in a nonjudgmental way by sharing information and observations about the child. This child exhibits symptoms of autism, which is not attributable to the actions of the parents. Asking the father about his relationship with his wife or how he held the child when she was an infant indirectly indicates that the parent may be at fault; it negates the father's need for support and increases his sense of guilt. Telling the father not to be concerned and stressing that the child will outgrow this developmental phase is false reassurance that does not provide support; the father recognizes that something is wrong. What is most appropriate for a nurse to say when interviewing a newly admitted depressed client whose thoughts are focused on feelings of worthlessness and failure? 1 "Tell me how you feel about yourself." 2 "Tell me what has been bothering you." 3 "Why do you feel so bad about yourself?" 4 "What can we do to help you while you're here?" ✓ Ans- 1 Because major depression is a result of the client's feelings of self-rejection, it is important for the nurse to have the client initially identify these feelings before developing a plan of care. Later discussion should be focused on other topics to prevent reinforcement of negative thoughts and feelings. "Tell me what has been bothering you" is asking the client to draw a conclusion; the client may be unable to do so at this time. Also, depression may be related not to external events but instead to a client's psychobiology. Asking why does not let a client explore feelings; it usually elicits an "I don't know" response. "What can we do to help you while you're here?" is beyond the scope of the client's abilities at this time. A client is admitted to the mental health unit with the diagnosis of major depressive disorder. Which statement alerts the nurse to the possibility of a suicide attempt? 1 "I don't feel too good today." 2."I feel much better; today is a lovely day." 3 "I feel a little better, but it probably won't last." 4 "I'm really tired today, so I'll take things a little slower." ✓ Ans- 2 A rapid mood upswing and psychomotor change may signal that the client has made a decision and has developed a plan for suicide. "I don't feel too good today"; "I feel a little better, but it probably won't last"; and "I'm really tired today, so I'll take things a little slower" are all typical of the depressed client; none of these statements signals a change in mood. During a group discussion it is learned that a group member hid suicidal urges and committed suicide several days ago. What should the nurse leading the group be prepared to manage? 1 Guilt of the co-leaders for failing to anticipate and prevent the suicide 2 Guilt of group members because they could not prevent another's suicide 3 Lack of concern over the suicide expressed by several of the members in the group 4.Fear by some members that their own suicidal urges may go unnoticed and that they may go unprotected ✓ Ans- 4 Ambivalence about life and death, plus the introspection commonly found in clients with emotional problems, can lead to increased anxiety and fear among the group members. These feelings must be handled within the support and supervisory systems for the staff; the group members are the primary concern. Guilt that the group's leaders or members might feel because they could not prevent another's suicide will probably be a secondary concern of the group leader. Lack of concern over the suicide expressed by several of the members in the group is not a primary concern, but this should be explored later to determine the reason for such apparent indifference, which may be a mask to cover true feelings. Which screening report will help the nurse determine skeletal growth in a child? 1 Electroencephalogram reports 2.Radiographs of the hand and wrist 3 Magnetic resonance imaging (MRI) 4 Denver Developmental Screening Test ✓ Ans- 2 Skeletal growth in a child can be determined from the ossification centers. At 5 to 6 months of age, the capitate and hamate bones in the wrist are the earliest centers. Therefore radiographs of the hand and wrist will help determine skeletal growth in the child. Electroencephalogram reports will help assess a child's brain activity. MRI is used to scan the internal structures of a client. The Denver Developmental Screening Test is used to understand developmental issues of a child. A client describes his delusions in minute detail to the nurse. How should the nurse respond? 1.Changing the topic to reality-based events 2 Continuing to discuss the delusion with the client 3 Getting the client involved in a social project with peers 4 Disputing the perceptions with the use of logical thinking ✓ Ans- 1 Decreasing time spent on delusions prevents reinforcement of psychotic thinking. Discussing reality-based events improves contact with reality. Encouraging discussion will give validity to the delusion. The client will have difficulty getting involved in a social activity; the activity will not stop the delusion. Challenging the client may increase anxiety. A nurse working on a mental health unit is caring for several clients who are at risk for suicide. Which client is at the greatest risk for successful suicide? 1 Young adult who is acutely psychotic 2 Adolescent who was recently sexually abused 3.Older single man just found to have pancreatic cancer 4 Middle-age woman experiencing dysfunctional grieving ✓ Ans- 3 Older single men with chronic health problems are at the highest risk of suicide. This is because men have fewer social supports than women do. (Men are less social then women in general.) Less social support at times of stress can increase the risk of suicide. Also, chronic health problems can lead to learned helplessness, which can lead to depression. People who are acutely psychotic as a group are at higher risk for suicide, but they do not have the suicide rate of older single adult men with chronic health problems. An adolescent who was recently sexually abused, although severely traumatized, does not have the risk of suicide of an older single man with chronic health problems. Dysfunctional grieving is prolonged grieving that is characterized by greater disability and dysfunctional patterns of behavior. Although people with complicated dysfunctional grieving may be at risk for selfdirected violence, they do not have the suicide risk of older single men with chronic health problems. Which stages would the nurse explain that a toddler goes through, according to Freud's theory? Select all that apply. 1 Oral 2 Anal 3 Phallic 4 Genital 5 Latency ✓ Ans- 1,2 According to Freud's theory, a toddler goes through the oral and anal stages. The phallic stage is seen in children between the ages of 3 to 6 years. The genital stage is seen during puberty through adulthood. The latency stage is seen in children ages 6 to 12 years of age. A client is found to have a borderline personality disorder. What behavior does the nurse consider is most typical of these clients? 1 Inept 2 Eccentric 3 Impulsive 4 Dependent ✓ Ans- 3 Impulsive