Situation: The nurse assigned to the detoxification unit attends to various patients with substance-related disorders. A 45 years old male revealed that he experienced a marked increase in his intake of alcohol to achieve the desired effect This indicates:

Correct Answer: B

Rationale: The correct answer is B: Tolerance. Tolerance refers to the need for increased amounts of a substance to achieve the desired effect over time. In this case, the patient's increased intake of alcohol to achieve the same effect indicates tolerance. Withdrawal (A) involves symptoms that occur when the substance is reduced or stopped. Intoxication (C) refers to the immediate effects of a substance on the body. Psychological dependence (D) involves a strong desire or craving for the substance, which is not explicitly indicated in the scenario.

Correct Answer: A

Rationale: The correct answer is A because revealing personal information to the client is a sign of countertransference. Countertransference occurs when the nurse projects their own feelings onto the client, blurring professional boundaries. Revealing personal information can indicate the nurse is overly involved or emotionally attached, impacting the therapeutic relationship. Choice B is incorrect because focusing on the client's feelings is a part of the therapeutic process and not necessarily indicative of countertransference. Choice C is incorrect as confronting discrepancies is a clinical intervention aimed at promoting insight, not necessarily a sign of countertransference. Choice D is incorrect as the client feeling anger towards the nurse who resembles his mother may be a transference reaction, not countertransference.

Correct Answer: D

Rationale: The correct answer is D because it directly addresses the client's behavior and emotions, inviting them to express their feelings. By acknowledging the pacing and inquiring about the client's emotions, the nurse shows empathy and helps the client recognize their anxiety. Option A assumes the client is worried, which may not be accurate. Option B suggests medication without exploring the underlying issue. Option C focuses on the duration of pacing rather than the client's emotional state.

Correct Answer: D

Rationale: The correct answer is D because informing the family about the potential effectiveness of medication in treating the distressing symptoms of schizophrenia is crucial. This information provides hope and encourages the family to support the individual in seeking appropriate treatment. Understanding that treatment is available can alleviate anxiety and promote acceptance. Choices A, B, and C are incorrect because while they provide valuable information, they are not as essential in the initial teaching session as knowing that treatment can help manage the symptoms.

Correct Answer: C

Rationale: The most appropriate nursing intervention for a client with Alzheimer's disease experiencing emotional lability is to reduce environmental stimuli to redirect attention (Choice C). This helps to minimize triggers that can exacerbate emotional outbursts. By creating a calm and less stimulating environment, the client's emotional responses may be more stable. Attempting humor (Choice A) may not be effective as it could be misinterpreted or escalate emotions. Exploring reasons for the client's mood (Choice B) may not be feasible due to cognitive impairments. Using logic (Choice D) may not be effective as clients with Alzheimer's may have difficulty processing logical reasoning.