Which assessment findings best correlate to the withdrawal from central nervous system depressants?

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: 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.

Correct Answer: D

Rationale: The correct answer is D because having one's only child leave home to attend college is an example of a maturational crisis. This event represents a significant life transition that can trigger emotional distress and force a reevaluation of one's identity and roles as a parent. It is a normal developmental milestone that signifies a shift in family dynamics and requires adjustment to an empty nest. A: Experiencing an unplanned pregnancy is not a maturational crisis as it is more related to a situational crisis. B: Losing one's job within months of retiring is not a maturational crisis but rather a situational crisis related to financial security. C: Working at a bank that was recently robbed is not a maturational crisis but a situational crisis related to work safety and stress.

Correct Answer: A

Rationale: The correct answer is A because it demonstrates the systematic and consistent implementation of evidence-based practice guidelines in documenting negative responses to suicidal ideation assessments for clients diagnosed with depression. This approach ensures that crucial information is captured regularly, aiding in monitoring and managing the clients' mental health effectively. Choice B focuses on the outcome of a specific treatment but does not directly address the implementation of evidence-based practice guidelines. Choice C expresses personal satisfaction rather than adherence to guidelines. Choice D reflects the client's subjective opinion and does not provide evidence of following specific guidelines. Thus, A is the correct choice as it directly relates to evidence-based practice implementation.