The nurse is caring for a female adolescent client diagnosed with depression and substance abuse. Which of the following would be most appropriate for the nurse to do?

Correct Answer: B

Rationale: The correct answer is B because asking about thoughts of harming herself is essential to assess suicide risk in clients with depression and substance abuse. It is crucial for the nurse to ensure the client's safety. Choice A is incorrect because hyperactivity is not typically associated with depression and substance abuse in adolescents. Choice C is incorrect because Wernicke's syndrome is not directly related to the client's current diagnoses. Choice D is incorrect because excessive anxiety, while important, is not as immediately critical as assessing suicide risk in this situation.

Correct Answer: D

Rationale: The correct answer is D: Autonomy versus shame and doubt. At 26 months, children are in the toddler stage where they are developing autonomy and independence. The child's negative behavior, refusal of toilet training, and constant use of "No!" suggest a struggle with asserting independence (autonomy) while also feeling the shame and doubt associated with not meeting expectations. This aligns with Erikson's psychosocial stage of Autonomy versus shame and doubt. A: Trust versus mistrust is resolved in infancy, where the child develops trust in caregivers. B: Initiative versus guilt occurs in early childhood when children explore their abilities and may feel guilty for overstepping boundaries. C: Industry versus inferiority is experienced in middle childhood, focusing on feelings of competence and accomplishment versus inadequacy. In summary, the child's behavior and resistance to toilet training indicate a conflict between asserting independence and feeling shame and doubt, which aligns with Autonomy versus shame and doubt.

Correct Answer: A

Rationale: The correct answer is A: Anxiety. The patient's behavior of monopolizing the conversation in a group therapy setting is likely a manifestation of anxiety. This behavior can be a coping mechanism to divert attention away from their own discomfort and vulnerability. By dominating the conversation, the patient may be attempting to maintain a sense of control and avoid facing their own underlying fears and anxieties. This behavior may also stem from a fear of being judged or feeling inadequate in the group setting. Choices B, C, and D are incorrect because anger, rebellion, and fear do not align as clearly with the behavior described in the scenario. Anger typically involves a different expression, rebellion would manifest differently, and fear would manifest more as withdrawal or avoidance rather than dominating the conversation.

Correct Answer: B

Rationale: Rationale: 1. Lorazepam is a fast-acting benzodiazepine used for acute anxiety relief. 2. It acts quickly to reduce anxiety symptoms. 3. Buspirone is not suitable for acute relief as it takes weeks to show effectiveness. 4. Amitriptyline and desipramine are tricyclic antidepressants, not fast-acting anxiolytics.

Correct Answer: B

Rationale: The correct answer is B: Cognition. The nurse is assessing the patient's thought process and decision-making abilities in response to a hypothetical scenario. By asking what the patient would do if experiencing fever and vomiting, the nurse is evaluating the patient's cognitive function. This question assesses the patient's ability to problem-solve, plan, and make decisions, which are key components of cognition. Summary: A: Behavior is incorrect as the question does not pertain to the patient's actions or reactions. C: Affect and mood are incorrect as the question does not focus on the patient's emotions. D: Perceptual disturbances are incorrect as the question does not relate to the patient's sensory perceptions.

Correct Answer: C

Rationale: The correct answer is C because instituting strict restrictions on the patient's activity is not appropriate when a patient is at imminent risk for suicide. This can increase feelings of hopelessness and powerlessness, potentially exacerbating the risk. Listening intently and nonjudgmentally (A), validating feelings (B), and using cognitive interventions to foster hope (D) are all appropriate strategies that can help support the patient and address the underlying issues contributing to their suicidal ideation. It is important to focus on therapeutic interventions that promote safety and provide support rather than imposing strict restrictions.

Correct Answer: C

Rationale: The correct answer is C: Self-awareness. Self-awareness is crucial in the nurse-patient relationship as it involves understanding one's own thoughts, emotions, values, and biases. This awareness helps nurses maintain objectivity, empathy, and effective communication with patients. By being self-aware, nurses can identify and manage their own feelings and reactions, leading to better understanding and connection with patients. Rationale for other choices: A: Rapport is important in building relationships, but self-awareness is essential for understanding and managing one's own behaviors and reactions within the relationship. B: Empathy is crucial for understanding and sharing patients' emotions, but self-awareness is fundamental for ensuring empathy is genuine and not influenced by personal biases. D: Values are important in guiding ethical decision-making, but self-awareness is necessary for recognizing how personal values may affect the nurse-patient relationship.

Correct Answer: B

Rationale: The correct answer is B because asking about thoughts of harming herself is essential to assess suicide risk in clients with depression and substance abuse. It is crucial for the nurse to ensure the client's safety. Choice A is incorrect because hyperactivity is not typically associated with depression and substance abuse in adolescents. Choice C is incorrect because Wernicke's syndrome is not directly related to the client's current diagnoses. Choice D is incorrect because excessive anxiety, while important, is not as immediately critical as assessing suicide risk in this situation.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Lamotrigine can cause a serious skin rash called Stevens-Johnson syndrome, so it's crucial for the client to notify their physician immediately if a skin rash develops. 2. Monitoring blood levels is not typically required for lamotrigine. 3. Watching salt intake is not directly related to lamotrigine use. 4. While lamotrigine can rarely affect liver function, it is not the primary concern compared to the potential serious skin rash.