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Which is an example of therapeutic communication?
- 'Don't worry, everything will be fine'
- 'Tell me more about what you are experiencing' ✓
- 'You shouldn't feel that way'
- 'I know exactly how you feel'
Therapeutic communication encourages clients to express thoughts and feelings, helps them work through issues, and supports the nurse-client relationship. Key techniques: (1) Open-ended questions/statements — invite elaboration ('Tell me more...', 'How are you feeling about...?'); (2) Active listeni…
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A client states 'I just can't take this anymore. I want to end it all.' What is the nurse's most appropriate initial response?
- 'Things will get better with time'
- 'Are you thinking of hurting yourself or ending your life?' ✓
- 'Don't say that — you have so much to live for'
- 'Let me change the subject'
When suicidal ideation is suggested or stated, the nurse must directly assess for suicide intent — this is the priority intervention. Asking about suicide does NOT plant the idea or increase risk; on the contrary, direct assessment is essential and may relieve the client. Assessment questions: (1) '…
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What are common symptoms of major depressive disorder?
- Increased energy
- Depressed mood, anhedonia (loss of interest), changes in appetite or weight, sleep disturbance, fatigue, psychomotor agitation or retardation, feelings of worthlessness or guilt, decreased concentration, thoughts of death or suicide — 5+ symptoms present for 2+ weeks ✓
- Manic episodes
- Hallucinations only
Major Depressive Disorder (DSM-5 criteria): five or more of the following symptoms present during the same 2-week period and representing a change from previous functioning. At least one symptom must be depressed mood or anhedonia. Symptoms: (1) Depressed mood most of the day, nearly every day — sad…
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What are characteristic features of bipolar disorder?
- Only depression
- Alternating episodes of mania (or hypomania) and depression — manic episodes feature elevated/irritable mood, increased energy, decreased sleep need, grandiosity, racing thoughts, pressured speech, distractibility, impulsivity ✓
- Constant happiness
- Identical to depression
Bipolar disorder involves episodes of mood elevation and depression. Mania (Bipolar I) — duration ≥7 days OR severe enough for hospitalization. Criteria: distinct period of abnormally elevated, expansive, or irritable mood AND increased goal-directed activity/energy; plus 3+ of (or 4+ if irritable):…
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What are the major features of schizophrenia?
- Mood swings only
- Positive symptoms (hallucinations, delusions, disorganized speech/behavior) and negative symptoms (affective flattening, alogia, avolition, anhedonia, asociality), with significant functional impairment, lasting 6+ months ✓
- Depression alone
- Anxiety only
Schizophrenia (DSM-5): 2+ symptoms present for significant portion of 1 month (or less if treated successfully): (1) Delusions — fixed false beliefs (persecutory, grandiose, somatic, religious, referential — believing TV is talking to you); (2) Hallucinations — false perceptions in any sense; audito…
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What are the symptoms of an anxiety attack/panic attack?
- Only mild worry
- Sudden, intense fear/discomfort with multiple physical symptoms: palpitations, sweating, trembling, shortness of breath, chest pain, nausea, dizziness, paresthesias, hot/cold flashes, fear of dying or losing control — usually peaks in 10 minutes ✓
- Hallucinations only
- Slow gradual onset
Panic Attack: a discrete period of intense fear or discomfort with abrupt onset, peaking within minutes, including 4+ symptoms: (1) Palpitations, pounding heart, or accelerated heart rate; (2) Sweating; (3) Trembling or shaking; (4) Shortness of breath or smothering sensation; (5) Choking sensation;…
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What are the five stages of grief described by Elisabeth Kübler-Ross?
- Hope, fear, peace
- Denial, Anger, Bargaining, Depression, Acceptance — not a linear progression; stages may be revisited, skipped, or occur in different order ✓
- Sad, mad, glad
- Three stages only
Kübler-Ross's five stages of grief (developed from observing dying patients in 'On Death and Dying,' 1969): (1) Denial — 'This can't be happening' — protects from initial shock; (2) Anger — 'Why me? It's not fair' — directed at self, others, healthcare team, God; (3) Bargaining — 'If only...' — atte…
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What is a 'crisis' in mental health, and what are the key principles of crisis intervention?
- Any disagreement
- A state of psychological disequilibrium where usual coping methods fail to resolve a stressor; crisis intervention is short-term (4-6 weeks typical), focused, problem-solving, mobilizing resources, restoring function — not deep therapy ✓
- Long-term therapy
- Just listening
A crisis is a state of disequilibrium caused by a stressor that overwhelms the person's usual coping abilities. Types of crisis: (1) Maturational/developmental — normal life transitions (marriage, parenthood, retirement) that overwhelm; (2) Situational — unexpected events (illness, loss, accident, d…
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What are the typical features of alcohol withdrawal?
- Only mild headache
- Onset 6-24 hours after last drink; symptoms include tremors, anxiety, nausea, sweating, increased BP/HR, insomnia; severe withdrawal includes seizures (24-48 hours), hallucinations (visual common), and delirium tremens (DTs) at 48-96 hours — DTs can be fatal ✓
- Resolves in hours
- No physical symptoms
Alcohol withdrawal occurs in people physically dependent on alcohol. Severity ranges from mild discomfort to life-threatening. Timeline: (1) 6-24 hours: minor withdrawal — tremors (especially hands), anxiety, headache, nausea/vomiting, sweating, increased pulse and blood pressure, insomnia, agitatio…
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What are the typical symptoms of opioid withdrawal?
- Life-threatening seizures
- Anxiety, restlessness, dilated pupils, muscle aches, diarrhea, nausea/vomiting, runny nose, tearing, yawning, sweating, chills, piloerection ('goosebumps'); unpleasant but not life-threatening in healthy adults ✓
- Identical to alcohol withdrawal
- No symptoms
Opioid withdrawal is uncomfortable but not life-threatening in healthy adults (unlike alcohol/benzodiazepine withdrawal). Symptoms: anxiety, restlessness, dysphoria; pupils dilated (mydriasis — opposite of intoxication which causes pinpoint pupils); muscle aches and bone pain; abdominal cramps, diar…
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What is the most effective response if a nurse suspects a colleague is impaired at work?
- Ignore it
- Report concerns through proper channels — typically to charge nurse or supervisor; protects patients and the colleague who needs intervention; mandatory in many state nurse practice acts; impaired nurse programs offer recovery support ✓
- Confront the colleague publicly
- Wait for someone else
Nurses have an ethical and (in most states) legal duty to report suspected impairment of colleagues. The behavior may be substance use, mental health issues, or medical conditions affecting function. Why report: (1) Patient safety — impaired nurses can harm patients through errors, missed observatio…
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What are healthy versus unhealthy coping mechanisms?
- All coping is healthy
- Healthy: exercise, social support, problem-solving, relaxation techniques, hobbies, professional help. Unhealthy: substance use, social isolation, denial, aggression, self-harm, overeating/restriction, excessive screen time, avoidance ✓
- All coping is unhealthy
- Coping is unnecessary
Coping mechanisms are strategies used to manage stress, emotions, and difficult situations. Healthy (adaptive) coping: (1) Problem-focused — addressing the stressor: planning, seeking information, taking action; (2) Emotion-focused (used when problem can't be changed) — acceptance, emotional support…
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What is 'cultural competence' in nursing care?
- Knowing one's own culture
- The ability to deliver care that recognizes, respects, and accommodates the cultural beliefs, values, practices, and needs of patients from diverse backgrounds — without stereotyping; requires self-awareness, knowledge, skill, and ongoing learning ✓
- Treating everyone identically
- Only relevant for some patients
Cultural competence is an essential nursing capability in increasingly diverse healthcare environments. Components: (1) Self-awareness — recognizing one's own cultural background, biases, and assumptions; (2) Cultural knowledge — understanding common health beliefs, practices, communication styles, …
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What is the appropriate approach to spiritual care in nursing?
- Always avoid religious topics
- Assess spiritual needs as part of holistic care; respect the patient's beliefs whether or not they match the nurse's; facilitate spiritual practices the patient values; refer to chaplaincy or the patient's clergy; do not impose one's own beliefs ✓
- Promote nurse's religion
- Pray with every patient
Spiritual care is part of holistic nursing — recognizing that spiritual well-being affects physical and mental health. Spirituality includes religious beliefs but extends beyond — meaning, purpose, connection, transcendence, values. Spiritual assessment: (1) Faith/Beliefs — what is important to you?…
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What is post-traumatic stress disorder (PTSD) and what are its key symptoms?
- Brief sadness after stress
- Mental health disorder following exposure to actual or threatened death, serious injury, or sexual violence; symptoms include intrusion (flashbacks, nightmares), avoidance, negative alterations in cognition/mood, and arousal/reactivity — lasting >1 month ✓
- Only physical injury
- Brief reaction
PTSD (DSM-5) develops in some individuals exposed to trauma — actual or threatened death, serious injury, or sexual violence. Exposure types: directly experiencing, witnessing, learning about (close family/friend), or repeated/extreme exposure (first responders). Symptoms persist >1 month and cause …
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A client with borderline personality disorder (BPD) alternates between telling one nurse 'You're the only one who understands me' and telling another 'She doesn't care about me at all.' This behavior pattern is called:
- Transference
- Splitting — seeing people as all good or all bad without integration; a hallmark defense mechanism in BPD ✓
- Projection
- Manipulation
SPLITTING is a primitive defense mechanism characteristic of BORDERLINE PERSONALITY DISORDER (BPD) in which the person cannot integrate the good and bad qualities of people (or themselves) and instead perceives them as either entirely good or entirely bad. In a clinical setting, splitting often mani…
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A client has been diagnosed with post-traumatic stress disorder (PTSD) following a motor vehicle accident. Which symptom cluster is MOST characteristic of PTSD?
- Grandiosity, decreased need for sleep, and racing thoughts
- Re-experiencing the trauma (flashbacks, nightmares), avoidance (of trauma reminders), negative cognitions/mood, and hyperarousal (exaggerated startle, hypervigilance, sleep disturbance) ✓
- Persistent sadness and anhedonia only
- Paranoid delusions and hallucinations
PTSD is a trauma- and stressor-related disorder defined by four symptom clusters (DSM-5), all present for more than 1 month following exposure to actual or threatened death, serious injury, or sexual violence: (1) RE-EXPERIENCING (INTRUSION): flashbacks (reliving the trauma as if it is happening now…
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A nurse responds to a client's tearful statement by saying, 'It sounds like you're feeling overwhelmed by everything that's happened.' This technique is called:
- Giving advice
- Reflection — restating the underlying feeling the client expressed to show understanding and invite further exploration ✓
- False reassurance
- Closed questioning
REFLECTION is a therapeutic communication technique in which the nurse communicates back the FEELING or CONTENT of what the client has expressed, demonstrating understanding and inviting the client to explore further. Two types: CONTENT REFLECTION — paraphrasing the facts or content ('So you're sayi…
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A client in alcohol withdrawal is assessed using the CIWA-Ar scale. Which score range indicates SEVERE withdrawal requiring close monitoring and aggressive pharmacological treatment?
- Score 0-9
- Score ≥15-20 (severe) — indicates high risk for withdrawal seizures and delirium tremens; requires IV benzodiazepines, intensive monitoring, and possible ICU-level care ✓
- Score 5-7
- Any score requires the same treatment
The CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT FOR ALCOHOL (CIWA-Ar) is a 10-item standardized scale used to assess alcohol withdrawal severity and guide treatment. CIWA-Ar ITEMS (each scored 0-7, except orientation which is 0-4): nausea/vomiting; tremor; paroxysmal sweats; anxiety; agitation; tactile…
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A nurse following the crisis intervention model responds to a client who reports their spouse just left them and they feel there is no reason to live. Which approach is CORRECT?
- Tell the client to call back when they have calmed down
- Assess for suicidal ideation using direct questioning, implement safety measures as indicated, provide crisis support, and connect the client to additional resources — crisis intervention focuses on immediate stabilization, not long-term therapy ✓
- Offer only general advice without safety assessment
- Refer the client to a support group only
CRISIS INTERVENTION is a short-term, active approach designed to help an individual in a crisis reach an acceptable level of functioning. A CRISIS is a temporary state of disequilibrium in which the person's usual coping mechanisms are insufficient for the situation. PHASES OF CRISIS INTERVENTION (R…
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A client with alcohol use disorder is in early recovery and asks the nurse about PAWS (Post-Acute Withdrawal Syndrome). What should the nurse explain?
- PAWS does not exist — all withdrawal symptoms resolve within a week
- PAWS involves prolonged neurological symptoms (anxiety, sleep disturbance, mood instability, cognitive difficulties, reduced stress tolerance) that can persist for weeks to months after acute withdrawal resolves — understanding PAWS helps clients recognize it and not mistake it for relapse ✓
- PAWS only occurs with opioid withdrawal
- PAWS is treated with benzodiazepines indefinitely
POST-ACUTE WITHDRAWAL SYNDROME (PAWS) — also called protracted withdrawal — is a second phase of withdrawal symptoms that emerge after the acute withdrawal phase resolves. CLINICAL PRESENTATION for alcohol (and other CNS depressants): Anxiety and irritability; sleep disturbances (insomnia, vivid dre…
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A nurse using motivational interviewing (MI) to help a client who is ambivalent about starting exercise for their heart disease. Which MI technique is the nurse using by saying, 'On one hand you're worried about your heart, and on the other hand exercise feels overwhelming. That's a real tension.'?
- Confrontation
- Reflective listening with double-sided reflection — acknowledging both sides of the client's ambivalence without judgment, which is the core technique of MI for building intrinsic motivation ✓
- Advice-giving
- Closed questioning
MOTIVATIONAL INTERVIEWING (MI) is an evidence-based, client-centered communication approach for facilitating behavior change in people who are ambivalent. CORE PRINCIPLES (RULE): Roll with Resistance; Understand the client's perspective; Listen with empathy; Empower the client. The FOUR PROCESSES: E…
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A client is admitted with first-episode psychosis. Which finding does NOT belong to the positive symptoms of schizophrenia?
- Auditory hallucinations
- Social withdrawal, flat affect, and poverty of speech — these are NEGATIVE symptoms (absence of normal function), not positive (excess/distorted function) ✓
- Delusions of grandeur
- Disorganized speech and behavior
SCHIZOPHRENIA SYMPTOM CLASSIFICATION — POSITIVE vs NEGATIVE SYMPTOMS: POSITIVE SYMPTOMS (presence of abnormal experiences not normally present): HALLUCINATIONS — false sensory perceptions; auditory most common in schizophrenia (hearing voices, often commenting, criticizing, or commanding); can be vi…
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A client's family asks if their loved one who is actively dying appears to be in pain. The client is unresponsive. What pain assessment approach should the nurse use?
- Unable to assess pain in unresponsive clients
- Use a behavioral pain observation scale (such as CPOT — Critical Pain Observation Tool — or PAINAD for dementia patients); observe for furrowed brow, grimacing, guarding, clenched teeth, rigid body, vocalizations; treat suspected pain proactively ✓
- Ask family if they think the patient is in pain and follow their answer
- Only assess for pain if the patient is moving
PAIN ASSESSMENT IN UNRESPONSIVE OR NON-VERBAL PATIENTS requires observational behavioral tools. The inability to self-report pain does NOT mean pain is absent — it means the nurse must observe for behavioral indicators. BEHAVIORAL PAIN SCALES FOR NON-VERBAL PATIENTS: CPOT (Critical-Pain Observation …
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A nurse is completing discharge teaching and the client says, 'I understand.' How should the nurse verify that understanding?
- Accept the statement and document 'client verbalized understanding'
- Use the teach-back method — ask the client to explain in their own words what they understand; 'Can you show me how you'll take your medication?' or 'What would you do if you noticed these warning signs?' — patient-demonstrated understanding is far more reliable than their self-report ✓
- Give the client a written handout and note it was provided
- Ask yes/no questions: 'Do you understand the diet?'
THE TEACH-BACK METHOD (also called the 'Show Me' method or Closing the Loop) is the evidence-based gold standard for verifying patient understanding of health education. WHY 'I UNDERSTAND' IS INSUFFICIENT: Studies show patients retain only 40-80% of what they are told; of what they retain, approxima…
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A client comes to the emergency department after disclosing suicidal ideation to a friend. The nurse's FIRST priority is:
- Call a psychiatrist
- Assess the level of risk — determine whether the client has a plan, a method, and intent; this structures the immediate safety response and level of care needed ✓
- Begin discharge paperwork
- Administer sedation
INITIAL SUICIDE RISK ASSESSMENT is the first priority because it determines the immediate safety response. ELEMENTS OF ASSESSMENT: IDEATION: Passive ('I wish I were dead') vs. active ('I am planning to kill myself'); PLAN: Specificity of plan (vague vs. specific date, method, location); METHOD: Avai…
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A dying client's family tells the nurse: 'We haven't told Mom she's dying — we don't want to upset her. Please don't tell her either.' How should the nurse respond?
- Agree to keep it secret from the client
- Acknowledge the family's love and protective intent; explain that the client has the ethical and legal right to information about their own health condition — the nurse cannot ethically deceive the client; offer to facilitate a family meeting with the palliative care team to address everyone's needs ✓
- Tell the client immediately without any preparation
- Side with the family to avoid conflict
TRUTH-TELLING AND PATIENT AUTONOMY: Clients have the ethical and legal right to information about their own health condition (autonomy). Withholding information from a competent client at the family's request violates this right and the nurse's ethical duty of veracity (truthfulness). CULTURAL CONTE…
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A client says: 'My doctor never explains anything to me. I don't understand what's happening.' The nurse's BEST response is:
- 'Your doctor is very busy. I'm sure they explained it.'
- 'What specifically has been confusing or unclear for you? Let me help you understand what I can, and we can identify what questions you want to ask your doctor.' ✓
- 'I'll tell the doctor to explain better.'
- 'Would you like me to arrange a patient advocate?'
THERAPEUTIC COMMUNICATION for expressed confusion: The best response: (1) VALIDATES the experience without dismissing or defending the physician; (2) EXPLORES the specific concern ('What specifically has been confusing') — this opens productive conversation rather than making assumptions; (3) OFFERS…
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A client with schizophrenia tells the nurse: 'The government has planted a device in my spine to monitor my thoughts.' What type of delusion is this?
- Grandiose
- Persecutory/paranoid — the belief that an external force is controlling, monitoring, or persecuting the client; this is the most common type of delusion in schizophrenia ✓
- Somatic
- Erotomanic
TYPES OF DELUSIONS: PERSECUTORY (most common in schizophrenia): Belief that someone or something is spying on, persecuting, or plotting against the client ('the government is monitoring me', 'my food is poisoned', 'I'm being followed'); GRANDIOSE: Belief that the client has special powers, status, o…
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A client who was just told they have cancer says: 'You must have the wrong chart. I was just at my annual physical last month and everything was fine.' Which defense mechanism is this?
- Rationalization
- Denial — the client is refusing to accept the reality of the diagnosis; denial is often the first response to catastrophic news and is a normal, potentially adaptive initial defense mechanism that allows gradual processing ✓
- Suppression
- Sublimation
DENIAL as initial response to catastrophic news is psychologically normal and may be adaptive. CHARACTERISTICS: Client rejects reality of the diagnosis or situation; may insist there is a mistake; may seek a second opinion (which can be healthy if not excessive); may continue discussing future plans…
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A client is admitted for alcohol withdrawal. Which symptom indicates the MOST life-threatening progression of withdrawal?
- Mild tremors
- Nausea and vomiting
- Delirium tremens (DTs) — characterised by confusion, agitation, hallucinations, hyperthermia, and autonomic instability (tachycardia, hypertension, diaphoresis); can progress to seizures and death if untreated ✓
- Insomnia and irritability
ALCOHOL WITHDRAWAL PROGRESSION: MILD (6-12 hours): Tremors, anxiety, nausea, diaphoresis, palpitations; MODERATE (12-48 hours): Same plus headache, vomiting, transient hallucinations (often visual/auditory), seizures (peak 24-48 hours); SEVERE — DELIRIUM TREMENS (48-96 hours): Life-threatening; diso…
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An elderly client tells the nurse: 'I have made peace with my life. I am ready to go.' According to Erikson's theory, which stage is reflected?
- Industry vs. Inferiority
- Ego Integrity vs. Despair — the final stage of Erikson's psychosocial development (late adulthood); successful resolution is ego integrity: the sense of having lived a meaningful, purposeful life; unsuccessful resolution is despair: regret, bitterness, and fear of death ✓
- Identity vs. Role Confusion
- Generativity vs. Stagnation
ERIKSON'S STAGES OF PSYCHOSOCIAL DEVELOPMENT — LATE ADULTHOOD (65+): STAGE: Ego Integrity vs. Despair; TASK: Reflect on life's meaning, accept one's life as it was lived, and face death with equanimity; SUCCESS (Ego Integrity): The person can say 'I am satisfied with the life I have lived'; they acc…
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A client with depression has not spoken during the last 10 minutes of a scheduled therapeutic interaction. What is the MOST therapeutic nursing response?
- End the session — silence means the client wants to be alone
- Ask a series of questions to fill the silence
- Sit quietly with the client, maintaining an open, accepting posture, using therapeutic silence — silence communicates that you are present, attentive, and comfortable without demanding conversation ✓
- Leave and return when the client is ready to talk
THERAPEUTIC SILENCE is an active, deliberate communication technique — not passive waiting. WHAT THERAPEUTIC SILENCE COMMUNICATES: 'You don't have to perform or produce for me'; 'I am here and attentive without demanding you speak'; 'Whatever you are experiencing right now is okay'; 'You have space …
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A client with major depressive disorder reports: 'I've been feeling much better lately. I've given away my jewelry and written a goodbye letter to my children.' What is the nurse's priority concern?
- The client is recovering and has improved insight
- This presentation is a HIGH-RISK WARNING for imminent suicide — giving away possessions and writing goodbye letters are behavioral indicators of suicidal intent; the client's reported 'improvement' may reflect resolution of ambivalence after deciding to act; this requires immediate safety assessment and intervention ✓
- The client needs follow-up in 2 weeks
- The client is experiencing a manic episode
PARADOXICAL IMPROVEMENT IN DEPRESSION is a well-documented and dangerous phenomenon: EXPLANATION: Severely depressed clients often lack the energy to act on suicidal thoughts; when they 'improve' slightly, they have enough energy to act but their hopelessness has not resolved; their apparent improve…
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A client with bipolar disorder is in a manic episode and has been awake for 3 days. Which nursing intervention is the HIGHEST priority?
- Schedule group therapy
- Encourage writing in a journal
- Ensure safety and promote rest/sleep — the client is in physiological danger from exhaustion, dehydration, and potential for impulsive dangerous behavior; environmental modifications (low stimulation, reduced lighting, quiet) and medication (mood stabilisers, adjunctive sedatives/antipsychotics) are the priority ✓
- Plan recreational activities
MANIA NURSING PRIORITIES: Safety is always first — mania creates serious risks: PHYSICAL: Exhaustion (3 days of sleep deprivation can cause hallucinations and medical complications); dehydration and poor nutrition (too agitated to eat/drink); cardiovascular strain from sustained hyperactivity; BEHAV…
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A bereaved spouse says: 'It's been 14 months since my wife died and I still cry every day — something must be wrong with me.' What is the most appropriate nursing response?
- 'You're right, 14 months is too long — you should seek medication'
- 'Grief has no set timeline. While intense acute grief typically evolves over the first year, it is normal to continue experiencing sadness and missing someone you loved deeply. The question is whether grief is impairing your ability to function in daily life' ✓
- 'By now you should be over it'
- 'You need psychiatric evaluation immediately'
COMPLICATED GRIEF vs NORMAL GRIEF: NORMAL GRIEF: Varies enormously between individuals; no set timeline; acute phase most intense first year; grief does not end — it transforms; sadness and missing the deceased indefinitely is NORMAL; COMPLICATED GRIEF (Prolonged Grief Disorder — DSM-5 2022): Persis…
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A client with terminal cancer says: 'I don't want my family to know how bad the pain is — they worry so much.' What does the nurse do?
- Honour the request completely and tell the family nothing
- Respect the client's decision about disclosure while ensuring their pain is adequately managed — explore the client's concerns about the family's emotional response; offer strategies for pain control that meet the client's needs; remind the client of available support; document the client's preferences ✓
- Tell the family everything immediately
- Insist the family must know
PATIENT CONFIDENTIALITY AND PAIN MANAGEMENT: PATIENT AUTONOMY: The client has the right to control what medical information is shared with family — even at end of life; confidentiality does not end when prognosis is terminal; COMPETING OBLIGATION: The nurse also has an obligation to ensure adequate …
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A teenager with a new type 1 diabetes diagnosis says: 'I don't care about this stupid disease — it won't change anything.' What does the nurse recognise?
- The teenager is medically compliant and healthy
- This statement may indicate denial or minimisation as a coping mechanism — adolescents with new chronic illness diagnoses often use denial to manage the psychological threat; the nurse should explore the statement without confrontation ✓
- The teenager is ready for discharge
- This is normal and requires no response
ADOLESCENT COPING WITH CHRONIC ILLNESS: DEVELOPMENTAL CONTEXT: Adolescents are establishing identity and peer belonging — a diagnosis of a chronic, visible disease (requiring injections, diet management, medical equipment) threatens both; denial and minimisation protect against the full psychologica…
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A client with borderline personality disorder (BPD) tells one nurse: 'You're the only one who understands me — the others are terrible nurses.' What interpersonal dynamic is this and how should the nurse respond?
- The client is being appropriately appreciative
- Splitting — a classic defence mechanism in BPD where people are viewed as all-good or all-bad; the nurse should acknowledge the client's feelings without reinforcing the splitting, maintain consistent boundaries, and communicate the pattern to the care team for consistent approach ✓
- The other nurses are probably poorly performing
- This is the client's right to a favourite nurse
SPLITTING IN BORDERLINE PERSONALITY DISORDER: DEFINITION: Seeing people as entirely good or entirely bad — unable to hold the ambivalent complexity that everyone is both; 'You're wonderful, everyone else is terrible'; RECOGNITION: Is a classic BPD interpersonal pattern; the 'wonderful' nurse gets id…
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A 45-year-old client is admitted for alcohol withdrawal monitoring. Which scale is used to standardise assessment and guide benzodiazepine dosing in alcohol withdrawal?
- PHQ-9
- Glasgow Coma Scale
- Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) — a 10-item scale assessing autonomic symptoms (HR, BP), tremor, diaphoresis, agitation, and hallucinations; scores guide symptom-triggered benzodiazepine administration (e.g., lorazepam if CIWA-Ar > 8-10) ✓
- CAGE questionnaire
CIWA-Ar SCALE: THE STANDARD: Most commonly used validated tool for alcohol withdrawal monitoring; ITEMS: Nausea/vomiting; tremor; diaphoresis; anxiety; agitation; tactile disturbances (formication); auditory disturbances; visual disturbances; headache; orientation/clouding; SCORING: 0-67 total; INTE…
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A nurse is providing therapeutic communication to an anxious pre-operative client. Which statement best demonstrates therapeutic technique?
- 'Don't worry — everything will be fine'
- 'Tell me what specifically is making you feel anxious about the surgery' ✓
- 'Thousands of people have this surgery every year without problems'
- 'Let me explain the statistics on surgical outcomes'
THERAPEUTIC COMMUNICATION — ANXIETY EXPLORATION: BEST RESPONSE: 'Tell me what specifically is making you feel anxious...' REASONS: Open-ended — invites the client to elaborate rather than answer yes/no; Client-specific — focuses on THIS client's concern, not generalisations; Actionable — identifies …
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A client prescribed lithium carbonate asks why they need blood tests. The nurse explains that lithium has a narrow therapeutic range. What are the signs of lithium toxicity?
- Hypertension and tachycardia
- Weight loss and insomnia
- Tremors, ataxia, slurred speech, confusion, and vomiting — early toxicity (1.5-2.0 mEq/L); severe toxicity (>2.0 mEq/L): seizures, cardiac arrhythmias, coma; therapeutic range is 0.6-1.2 mEq/L (maintenance) or 0.8-1.2 mEq/L (acute) ✓
- Euphoria and hyperactivity
LITHIUM TOXICITY — HIGH-YIELD NCLEX CONTENT: THERAPEUTIC RANGE: 0.6-1.2 mEq/L (some sources 0.8-1.2 for bipolar treatment); TOXIC LEVELS: >1.5 mEq/L early toxicity; >2.0 mEq/L serious toxicity; EARLY TOXICITY SIGNS: Coarse tremors; nausea/vomiting; diarrhoea; polyuria; ataxia (coordination problems)…
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A nurse calls security after a client with paranoid schizophrenia becomes increasingly agitated and is threatening to hit staff. After de-escalation fails, the client must be physically restrained. What is the nurse's priority during the restraint process?
- Ensure the most staff are involved to look authoritative
- Protect the client's airway and monitor vital signs during and immediately after the restraint — physical restraint carries risk of positional asphyxia (particularly prone restraint), excited delirium, and cardiac events; monitor breathing and oxygenation continuously ✓
- Document first, then assist
- Focus only on protecting staff
SAFETY DURING PHYSICAL RESTRAINT: RESTRAINT RISKS: POSITIONAL ASPHYXIA: If face-down (prone) restraint is used, chest compression restricts breathing; risk of death; EXCITED DELIRIUM: State of extreme agitation with high sympathetic drive; risk of sudden cardiac death during or after restraint; MONI…
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A nurse notices that a client who was just informed they need chemotherapy immediately begins explaining to family members the detailed biology of cancer cell growth and treatment mechanisms. What coping mechanism is this?
- Repression
- Intellectualisation — using abstract thinking, facts, and intellectual analysis to emotionally distance oneself from the threatening aspects of a diagnosis; the client is engaging with the intellectual content while avoiding emotional processing ✓
- Regression
- Sublimation
INTELLECTUALISATION: Converting a threatening emotional situation into an intellectual exercise to manage anxiety; PRESENTATION: The individual becomes an 'expert' on their diagnosis; researches every detail; discusses statistics and biology; may appear calm and in control; DISTINGUISHED FROM: Healt…
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During a home visit, the nurse observes that a cognitively intact older adult client has bruising in various stages of healing, appears frightened when their adult child is present, and winces when the child reaches toward them. What must the nurse do?
- Assume it is accidental and document the bruises only
- This presentation requires mandatory reporting to adult protective services — these are multiple red flags for elder abuse (unexplained bruising in various stages, fear of caregiver, flinching response); nurses are mandatory reporters of suspected elder abuse in all states ✓
- Ask the adult child what happened and accept their explanation
- Advise the client to see a doctor
ELDER ABUSE IDENTIFICATION AND MANDATORY REPORTING: RED FLAGS PRESENT: Multiple bruises in various stages (suggests repeated injury); fear response to caregiver; flinching (anticipatory fear of being struck); TYPES OF ELDER ABUSE: Physical (most visible); emotional/psychological; sexual; financial; …
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A client is admitted with anorexia nervosa. Which finding is the highest priority for the nurse to monitor?
- The client's distorted body image
- Cardiac status and electrolyte imbalances — particularly hypokalemia and cardiac dysrhythmias, which are the leading cause of death in anorexia nervosa ✓
- The client's social withdrawal
- The client's perfectionism
ANOREXIA NERVOSA — PHYSIOLOGICAL PRIORITY: While the psychological aspects (body image distortion, control issues) are central to the disorder, the IMMEDIATE LIFE THREAT is physiological. CARDIAC AND ELECTROLYTE COMPLICATIONS are the leading cause of death: Hypokalemia (low potassium) → fatal cardia…
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A client with borderline personality disorder tells the nurse, 'You're the only one who understands me. The other nurses are terrible.' What is the best nursing response?
- 'Thank you, I do try harder than the others.'
- Recognize this as 'splitting' (idealization/devaluation) and respond with a consistent, professional approach — set clear boundaries and avoid being drawn into the idealization; the treatment team maintains consistency to avoid manipulation ✓
- Agree that the other nurses could do better
- Avoid the client to prevent the behavior
BORDERLINE PERSONALITY DISORDER — SPLITTING: A hallmark defense mechanism where the client views people as all-good (idealization) or all-bad (devaluation), often shifting rapidly. The statement 'you're the only one who understands me, others are terrible' is classic splitting. NURSING RESPONSE: Mai…
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A client in alcohol withdrawal is being monitored using the CIWA-Ar scale. What does a rising CIWA-Ar score indicate?
- Improvement in withdrawal symptoms
- Worsening withdrawal severity — a rising score indicates escalating symptoms and the need for more aggressive treatment (typically benzodiazepine dosing) to prevent progression to seizures or delirium tremens ✓
- The client is ready for discharge
- Successful detoxification
CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised): A validated 10-item scale that quantifies alcohol withdrawal severity. ITEMS: Nausea/vomiting, tremor, sweating, anxiety, agitation, tactile/auditory/visual disturbances, headache, orientation; SCORING: Higher score = more seve…
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A nurse is caring for a client who survived a violent assault. The client is experiencing acute stress and says, 'I keep seeing it happen over and over.' Which intervention is most appropriate during the acute phase?
- Encourage the client to forget about the event
- Provide a safe, calm environment, allow the client to express feelings at their own pace, validate their experience, and ensure basic needs and safety — avoid forcing the client to recount details or pushing for emotional processing prematurely ✓
- Immediately confront the trauma in detail
- Tell the client they are lucky to be alive
ACUTE STRESS / TRAUMA RESPONSE — CRISIS INTERVENTION: In the acute phase after trauma, the priorities are SAFETY, STABILIZATION, and SUPPORT — not deep emotional processing. APPROPRIATE INTERVENTIONS: Ensure physical safety and basic needs; provide a calm, safe environment; allow the client to expre…
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A client is taking lithium for bipolar disorder. The client reports nausea, vomiting, diarrhea, coarse hand tremors, and confusion. What does the nurse suspect?
- Normal side effects that will resolve
- Lithium toxicity — these are signs of elevated lithium levels; hold the lithium, check the serum lithium level, and notify the provider; lithium has a narrow therapeutic range (0.6-1.2 mEq/L) ✓
- An unrelated viral illness
- Improvement in mood symptoms
LITHIUM TOXICITY: Lithium has a NARROW THERAPEUTIC RANGE (0.6-1.2 mEq/L) — toxicity can occur even slightly above range. EARLY TOXICITY (1.5-2.0 mEq/L): Nausea, vomiting, diarrhea, fine tremor worsening, drowsiness, muscle weakness; MODERATE-SEVERE (2.0-2.5+): COARSE tremors, confusion, ataxia, slur…
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A client with major depression states, 'There's no point in any of this. Nothing will ever get better.' What is the priority nursing assessment in response to this statement?
- Assess the client's sleep patterns
- Assess for suicidal ideation — hopelessness and statements suggesting life is pointless are warning signs that require direct assessment of suicidal thoughts, plan, and intent ✓
- Assess the client's appetite
- Assess the client's family support
HOPELESSNESS AND SUICIDE RISK: Statements expressing hopelessness ('nothing will ever get better,' 'no point') are significant suicide warning signs. HOPELESSNESS is one of the strongest predictors of suicide. PRIORITY: Directly assess for suicidal ideation — ask directly: 'Are you having thoughts o…
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A client experiencing a panic attack is hyperventilating and says, 'I think I'm having a heart attack — I'm going to die.' After medical causes are ruled out, what is the most therapeutic nursing intervention?
- Leave the client alone to calm down
- Stay with the client, remain calm, speak in short simple sentences, and guide slow breathing — your calm presence and reassurance help the client regain control during the panic attack ✓
- Tell the client there's nothing wrong and to relax
- Administer oxygen at high flow
PANIC ATTACK — ACUTE NURSING INTERVENTION: Once medical causes (cardiac, respiratory) are ruled out, the therapeutic approach is calm, supportive presence. INTERVENTIONS: STAY with the client (do not leave them alone — abandonment increases panic); remain CALM yourself (anxiety is contagious; calmne…
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A nurse uses the therapeutic communication technique of 'reflection.' Which response is an example of reflection?
- 'Why do you feel that way?'
- 'You're feeling frightened about the surgery tomorrow.' — reflection restates the client's feelings or content to show understanding and encourage further exploration ✓
- 'Everything will be fine, don't worry.'
- 'You should talk to your doctor about that.'
REFLECTION — A THERAPEUTIC COMMUNICATION TECHNIQUE: Reflection restates or mirrors the client's expressed feelings or content, demonstrating active listening and encouraging the client to continue. EXAMPLE: Client: 'I'm so scared about the surgery.' Nurse (reflection): 'You're feeling frightened abo…
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A client with obsessive-compulsive disorder (OCD) performs hand-washing rituals for hours, causing skin breakdown. During the acute phase, what is the most therapeutic initial nursing approach?
- Prevent the client from performing the ritual entirely
- Allow the ritual while ensuring safety (skin care), then gradually work with the treatment team to set limits and reduce the behavior — abruptly preventing a compulsion increases anxiety severely; structure and gradual reduction are therapeutic ✓
- Ignore the behavior completely
- Punish the client when they perform the ritual
OCD — COMPULSIONS AND NURSING APPROACH: Compulsions are anxiety-reducing rituals; the client feels compelled to perform them to relieve obsession-driven anxiety. INITIAL APPROACH: Do NOT abruptly stop the ritual — preventing a compulsion suddenly causes severe, sometimes intolerable anxiety; ALLOW t…
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A nurse is assessing a client who may be a victim of intimate partner violence (IPV). What is the most appropriate way to conduct this assessment?
- Ask about abuse in front of the client's partner
- Interview the client ALONE, in a private and safe setting, using direct but nonjudgmental questions — never assess for abuse in the presence of the suspected abuser ✓
- Wait for the client to bring it up themselves
- Only assess if there are visible injuries
INTIMATE PARTNER VIOLENCE (IPV) ASSESSMENT: PRIVACY AND SAFETY: Always interview the client ALONE — never assess for abuse with the partner present (the abuser may control the narrative, intimidate, or the client may fear retaliation); ensure a private, safe setting; APPROACH: Direct but nonjudgment…
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A nurse is caring for a client with dementia who becomes agitated and combative in the late afternoon and evening. This pattern is known as:
- Delirium
- Sundowning — increased confusion, agitation, and behavioral disturbances that occur in the late afternoon and evening in clients with dementia; managed with environmental and routine modifications ✓
- Psychosis
- Catatonia
SUNDOWNING: A pattern of increased confusion, agitation, anxiety, and behavioral disturbances that occurs in the LATE AFTERNOON AND EVENING in some clients with dementia. CONTRIBUTING FACTORS: Fatigue, reduced lighting/increased shadows, disrupted circadian rhythm, overstimulation or understimulatio…
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A client who is grieving the recent death of a spouse says, 'I just don't know how I'll go on without them.' What is the most therapeutic response?
- 'Time heals all wounds. You'll feel better soon.'
- 'You're feeling lost and overwhelmed right now. Tell me about your spouse.' — acknowledging the feeling and inviting the client to share supports healthy grieving ✓
- 'At least they're not suffering anymore.'
- 'You need to stay strong for your family.'
GRIEF SUPPORT — THERAPEUTIC COMMUNICATION: The most therapeutic response acknowledges the client's feelings and invites them to express their grief. EXAMPLE: Reflecting the feeling ('you're feeling lost and overwhelmed') and inviting expression ('tell me about your spouse') validates the grief and s…
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A client is prescribed an MAOI (monoamine oxidase inhibitor) antidepressant. Which dietary teaching is essential?
- Increase protein intake
- Avoid foods high in tyramine (aged cheeses, cured meats, fermented foods, draft beer, soy sauce) — combining MAOIs with tyramine can cause a hypertensive crisis, a life-threatening emergency ✓
- Avoid all carbohydrates
- Drink grapefruit juice daily
MAOI DIETARY RESTRICTIONS — TYRAMINE: MAOIs (phenelzine, tranylcypromine, isocarboxazid, selegiline) inhibit the enzyme that breaks down tyramine; consuming tyramine-rich foods while on an MAOI causes a dangerous spike in blood pressure (HYPERTENSIVE CRISIS). TYRAMINE-RICH FOODS TO AVOID: Aged chees…
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During a community disaster with mass casualties, the mental health nurse is providing psychological first aid. What is the primary goal of psychological first aid?
- Provide formal psychotherapy on-site
- Reduce initial distress, meet immediate needs, and foster adaptive coping and a sense of safety — psychological first aid is supportive, practical, and aims to stabilize, not to provide formal therapy or force people to process the trauma ✓
- Diagnose mental health disorders
- Identify who needs psychiatric hospitalization
PSYCHOLOGICAL FIRST AID (PFA): An evidence-informed approach for helping people in the immediate aftermath of disaster or trauma. PRIMARY GOALS: Reduce initial distress; meet immediate practical needs (safety, food, shelter, information); foster adaptive coping and resilience; connect people with su…
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A client is being treated with electroconvulsive therapy (ECT) for severe, treatment-resistant depression. What is the most common side effect the nurse should anticipate and address?
- Permanent personality change
- Transient memory loss and confusion — short-term memory impairment and temporary confusion are the most common side effects after ECT; they typically resolve over days to weeks ✓
- Paralysis
- Hair loss
ELECTROCONVULSIVE THERAPY (ECT): An effective treatment for severe, treatment-resistant depression, acute mania, and catatonia, especially when rapid response is needed or medications have failed. PROCEDURE: Brief electrical stimulation induces a controlled seizure under general anesthesia with a mu…
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A client with depression states, 'I just don't see the point in anything anymore.' What is the nurse's priority response?
- 'Things will get better soon.'
- Assess for suicidal ideation by asking directly, 'Are you having thoughts of harming yourself or ending your life?' ✓
- 'You have so much to live for.'
- Change the subject to something positive
A statement of HOPELESSNESS ('don't see the point in anything') from a depressed client is a potential warning sign — the PRIORITY is to ASSESS for SUICIDAL IDEATION by asking DIRECTLY ('Are you having thoughts of harming yourself or ending your life?'). NCLEX psychosocial/mental health safety. Aski…
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A client is crying after receiving difficult news. Which nursing action best demonstrates therapeutic presence?
- Leave the room to give privacy and avoid intruding
- Sit with the client, offer a tissue, and allow silence, conveying support and a willingness to listen ✓
- Tell the client to stop crying
- Immediately offer detailed medical advice
Therapeutic PRESENCE after difficult news: SIT WITH the client, offer comfort (a tissue), and ALLOW SILENCE — conveying support, empathy, and a willingness to listen without rushing. NCLEX psychosocial/therapeutic communication. SILENCE is a therapeutic technique — it gives the client time to proces…
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A nurse is caring for a client experiencing a manic episode (bipolar disorder). Which intervention is appropriate?
- Encourage participation in highly stimulating group activities
- Provide a calm, low-stimulation environment and offer high-calorie finger foods the client can eat while moving ✓
- Serve large sit-down meals
- Engage the client in lengthy detailed conversations
For a client in a MANIC episode (hyperactivity, racing thoughts, poor judgment, distractibility, decreased need for sleep, risk-taking): provide a CALM, LOW-STIMULATION environment (reduces escalation); offer HIGH-CALORIE, easy-to-eat FINGER FOODS the client can consume WHILE MOVING (manic clients o…
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A nurse suspects that a client may be a victim of domestic abuse. What is the most appropriate nursing action?
- Confront the suspected abuser directly
- Interview the client ALONE (without the suspected abuser present), in a private, nonjudgmental manner, and assess for safety ✓
- Ignore it unless the client brings it up
- Tell the client to leave the relationship immediately
When abuse is suspected, the nurse should interview the client ALONE — separating them from the suspected abuser (who may control or speak for the victim) — in a PRIVATE, safe, NONJUDGMENTAL setting, and assess for safety. NCLEX psychosocial/abuse. KEY ACTIONS: ensure privacy and the abuser is not p…
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A client with anorexia nervosa is hospitalized. During meals, which nursing approach is most therapeutic?
- Allow the client to eat alone without observation
- Provide a supportive, structured mealtime environment and observe the client during and after meals (to prevent purging or food disposal) ✓
- Force-feed the client immediately
- Comment on every bite the client takes
For a hospitalized client with ANOREXIA NERVOSA, mealtime care includes: a SUPPORTIVE, STRUCTURED environment with consistent expectations; OBSERVING the client DURING and AFTER meals (typically remaining with them and for a period after — often ~1 hour — to prevent hiding/disposing of food, purging…