When working with a patient beginning treatment for alcohol dependence, what is the nurse’s most therapeutic approach?

Correct Answer: A

Rationale: The correct answer is A: Empathetic, supportive. This approach establishes trust, shows understanding, and promotes open communication. Empathy helps build a therapeutic relationship, which is crucial in treating alcohol dependence. Being supportive encourages the patient to feel safe and willing to discuss their issues. Strong, confrontational (B) may lead to resistance and defensiveness. Skeptical, guarded (C) can create barriers and hinder progress. Cool, distant (D) may make the patient feel isolated and unsupported. Overall, empathy and support create a positive and collaborative therapeutic environment.

Correct Answer: C

Rationale: The correct answer is C because the assessment findings of nausea, vomiting, diaphoresis, anxiety, and tremors are classic symptoms of withdrawal from central nervous system depressants such as alcohol or benzodiazepines. Nausea and vomiting can result from the body's attempt to expel the toxic substance, diaphoresis can occur due to increased sympathetic activity, anxiety and tremors are common manifestations of central nervous system hyperactivity during withdrawal. The other choices (A, B, D) do not align with the typical withdrawal symptoms of CNS depressants and are more indicative of other conditions or substances.

Correct Answer: A

Rationale: The correct answer is A because for a patient who has ingested LSD, it is important to have someone stay with them and provide verbal support due to the potential for anxiety and panic attacks. This helps in grounding the patient and providing reassurance. On the other hand, for a patient who has ingested PCP, a regimen of limited contact with staff members is maintained to prevent potential aggression or unpredictable behavior. Continual visual monitoring is provided to ensure safety without directly engaging with the patient. Choice B is incorrect because placing a patient on one-on-one intensive supervision for PCP ingestion may escalate the situation due to potential paranoia or aggression. Choice C is incorrect because LSD ingestion may lead to sensory overload, so providing moderate sensory stimulation is more appropriate. Choice D is incorrect because restraints for LSD ingestion are not necessary and seizure precautions are not typically needed for PCP ingestion.

Correct Answer: A

Rationale: The correct answer is A: Chronic low self-esteem. The patient's statement reflects long-standing feelings of inadequacy and worthlessness, indicating a chronic issue rather than a temporary situation (situational low self-esteem). The statement also reveals a negative perception of self, which aligns with chronic low self-esteem. Disturbed personal identity refers to confusion in one's sense of self, which is not evident in the patient's statement. Ineffective health maintenance pertains to the inability to identify, manage, and seek help for health problems, which is not the primary issue in this scenario. Therefore, A is the most appropriate nursing diagnosis.

Correct Answer: A

Rationale: The correct answer is A because actively listening allows the nurse to show empathy, understanding, and respect towards the client, which are essential for building a therapeutic relationship. By actively listening, the nurse can demonstrate genuine interest in the client's thoughts and feelings, fostering trust and rapport. Choice B is incorrect as intervening when the client expresses beliefs from their illness may disrupt the client's expression and hinder the development of trust. Choice C is incorrect because evaluating behaviors and relationships may create a sense of judgment and lack of privacy, which can be detrimental to the therapeutic relationship. Choice D is incorrect because passively allowing the client to control communication may lead to a lack of direction and boundaries, potentially hindering effective communication and rapport-building.