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?

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.

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.

Correct Answer: C

Rationale: The correct answer is C, Establishment of the National Institute of Mental Health (NIMH), as a result of the National Mental Health Act. This is because the National Mental Health Act of 1946 led to the creation of NIMH in 1949. NIMH is dedicated to research on mental illnesses and disorders, promoting mental health, and providing resources for mental health professionals and the public. Choice A, Discovery of psychopharmacology, is incorrect as it is not a direct result of the National Mental Health Act. Choice B, Passage of the Hill-Burton Act, is also incorrect as it focused on improving hospital facilities, not specifically mental health care. Choice D, Development of community mental health centers, is incorrect as it was a result of the Community Mental Health Centers Act of 1963, not the National Mental Health Act.

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.

Correct Answer: B

Rationale: The correct answer is B: A Cobb salad with blue cheese and Roquefort salad dressing. Phenelzine is a monoamine oxidase inhibitor (MAOI), which can interact with foods high in tyramine, such as aged cheeses like blue cheese and Roquefort. The interaction can lead to a hypertensive crisis, posing a serious health risk for the client. Choices A, C, and D are all safe options as they do not contain high levels of tyramine-rich foods that can interact with phenelzine.

Correct Answer: B

Rationale: The correct answer is B because three out of the four criteria listed by the student are correct. (1) an appropriate perception of reality, (2) the ability to accept oneself, and (3) the ability to establish relationships are indeed important criteria for good mental health. However, (4) a need for detachment and the desire for privacy is not typically considered a criteria for good mental health. It is important to emphasize that maintaining healthy boundaries and privacy is essential, but it is not a defining criteria for good mental health. Therefore, the student's list is good but not perfect.

Correct Answer: B

Rationale: The correct answer is B because when the nurse has a therapeutic relationship with the client, it means they work collaboratively. The nurse considers the client a partner in care planning, involving them in decision-making and respecting their autonomy. This approach fosters trust and empowers the client in their care. A: The nurse should maintain professional boundaries and not become friends with the client to avoid conflicts of interest. C: Adhering strictly to the plan of care without flexibility may not meet the client's individual needs and preferences. D: While avoiding a directive approach is important, there are times when the nurse needs to provide guidance and direction for the client's benefit.

Correct Answer: D

Rationale: The correct answer is D: Direct confrontation to solve problems. This Western cultural feature may result in establishing unrealistic outcomes for patients of other cultural groups because direct confrontation may be perceived as aggressive or disrespectful in many cultures. Patients from these cultural groups may prefer indirect communication or conflict resolution methods. Therefore, using direct confrontation could lead to misunderstandings, resistance, or lack of cooperation from patients. A: Interdependence is a common cultural value in many cultures and does not necessarily lead to unrealistic outcomes for patients of other cultural groups. B: Present orientation is a temporal orientation and does not directly impact outcomes for patients from other cultural groups. C: Flexible perception of time may differ across cultures but does not inherently lead to unrealistic outcomes for patients of other cultural groups.

Correct Answer: A

Rationale: Step-by-step rationale: 1. Giving advice can create dependency on the advisor. 2. It may hinder the individual's ability to think for themselves. 3. Encouraging self-reliance and problem-solving is more effective. 4. Therefore, giving advice is rarely helpful in promoting independence and personal growth. Summary of other choices: B. Fostering independence would involve guiding individuals to make their own decisions. C. Lifting the burden of decision-making could lead to reliance on external opinions rather than self-reflection. D. Developing feelings of personal adequacy is better achieved through self-discovery and empowerment rather than being told what to do.