A client has had a major stroke and is struggling

Question 1 of 5

A client has had a major stroke and is struggling to adjust to living with consequent changes and permanent disabilities related to speech and mobility. The nurse assesses the client closely based on the understanding that the client is at increased risk for which of the following?

A. Bipolar I disorder B. Major depressive disorder C. Generalized anxiety disorder D. Posttraumatic stress disorder

Correct Answer: B

Rationale: The correct answer is B: Major depressive disorder. Following a major stroke, individuals often experience feelings of grief, sadness, and hopelessness due to the significant life changes and disabilities. This can lead to the development of major depressive disorder. Depression is common post-stroke due to neurobiological changes and psychosocial factors. The other choices are incorrect because bipolar I disorder is characterized by distinct episodes of mania and depression, which are not directly related to stroke. Generalized anxiety disorder and posttraumatic stress disorder are also not directly associated with the typical emotional response following a stroke.

Question 2 of 5

Which individual is demonstrating the highest level of resilience? One who

A. is able to repress stressors. B. becomes depressed after the death of a spouse. C. lives in a shelter for 2 years after the home is destroyed by fire. D. takes a temporary job to maintain financial stability after loss of a permanent jo

Correct Answer: D

Rationale: The correct answer is D because the individual demonstrates resilience by adapting to the loss of a permanent job through taking a temporary job to maintain financial stability. This shows resilience as they are actively seeking solutions to overcome adversity. A is incorrect as repressing stressors is not a healthy coping mechanism for resilience. B is incorrect as becoming depressed after the death of a spouse indicates a lack of resilience in handling the emotional stress. C is incorrect as living in a shelter for 2 years after a fire is a challenging situation, but it does not necessarily demonstrate the same level of adaptation and proactive approach to adversity as taking a temporary job for financial stability.

Question 3 of 5

A client with Alzheimer's disease is admitted to the acute care facility for treatment of an infection. Assessment reveals that the client is anxious. When developing the client's plan of care, which of the following would be least appropriate to include?

A. Frequently provide reality orientation. B. Simplify the client's routines. C. Limit the number of choices to be made. D. Establish predictable routines.

Correct Answer: A

Rationale: The correct answer is A because frequently providing reality orientation may increase the client's anxiety due to the inability to retain new information. Choice B is correct as simplifying routines can reduce confusion. Choice C is correct as limiting choices can decrease anxiety. Choice D is correct as establishing predictable routines can provide a sense of security and familiarity.

Question 4 of 5

A nurse identifies the nursing diagnosis of Ineffective Sexuality Patterns based on which of the following?

A. The sexual problem is causing dissatisfaction for the client. B. The client has experienced a change in sexual functioning. C. The client is feeling inadequacy related to the sexual problem. D. The client believes that sexual activity is unrewarding.

Correct Answer: B

Rationale: The correct answer is B because identifying Ineffective Sexuality Patterns involves recognizing a change in the client's sexual functioning, which is a key criterion for this nursing diagnosis. A: Dissatisfaction alone does not necessarily indicate ineffective sexuality patterns. C: Feeling inadequacy is related to self-esteem, not specifically to sexual functioning. D: Perceiving sexual activity as unrewarding does not directly address changes in sexual functioning, which are crucial in diagnosing ineffective sexuality patterns.

Question 5 of 5

A nurse is talking with a 57-year-old client who has been a heavy drinker for many years. The client is being treated for alcoholism, and this is her second week as an inpatient on the psychiatric unit. It is 5:00 AM, and the client has been having difficulty sleeping. The client is an orthopedic nurse, and although she is clothed in a hospital-issued gown and robe, she is wearing a stethoscope around her neck that the nurse recognizes as belonging to one of the staff nurses. When the nurse asks her why she is wearing the stethoscope and where she got it, the client gives her a long and involved reply that basically describes how her nursing supervisor came to visit and gave it to her to wear 'so she'd remember to get well.' The nurse suspects that the client may be experiencing which of the following?

A. Wernicke's syndrome B. Delirium tremens C. Korsakoff's psychosis D. Malignant hyperthermia

Correct Answer: C

Rationale: Rationale: The correct answer is C: Korsakoff's psychosis. This is because the client's long and involved reply with false information about receiving the stethoscope from her nursing supervisor is indicative of confabulation, a common symptom of Korsakoff's psychosis. This condition is typically associated with chronic alcohol abuse and thiamine deficiency, leading to memory issues and confabulation. Incorrect options: A: Wernicke's syndrome is characterized by a triad of symptoms including confusion, ataxia, and ophthalmoplegia, not confabulation. B: Delirium tremens is a severe form of alcohol withdrawal that presents with hallucinations, tremors, and autonomic instability, not confabulation. D: Malignant hyperthermia is a rare but life-threatening reaction to certain medications used during anesthesia, not related to the client's behaviors or symptoms described in the scenario.