Correct Answer: C

Rationale: The correct answer is C: "I will address the problem that the client believes is the most significant." This response demonstrates an understanding of client-centered care, which is essential when working with vulnerable populations. By acknowledging and addressing the client's perceived most significant problem, the nurse shows empathy and respect for the client's perspective. This approach helps build trust and rapport, leading to better outcomes.


Choice A is incorrect because doing a limited assessment focused solely on the client's stated reason may overlook important underlying issues that could impact the client's health and well-being.
Choice B is incorrect as asking for income or financial information may be necessary to determine eligibility for certain services or assistance, and it is not necessarily an invasion of privacy if done in a professional and confidential manner.


Choice D is incorrect because cultural traditions play a significant role in a client's healthcare beliefs and practices, and excluding them from the assessment could lead to misunderstandings or ineffective care.

Correct Answer: D

Rationale: The correct answer is D: Increased heart rate and vomiting. During alcohol withdrawal, the body experiences sympathetic nervous system overactivity, leading to increased heart rate as a result of elevated levels of adrenaline. Vomiting can occur due to gastrointestinal distress and autonomic nervous system dysregulation.

A: Decreased blood pressure and nausea are not typical findings in alcohol withdrawal. Alcohol withdrawal commonly presents with elevated blood pressure and other symptoms such as tremors and anxiety.
B: Constipation and pupil constriction are not typical symptoms of alcohol withdrawal. Instead, diarrhea and dilated pupils can occur.
C: Bone and muscle aches are not specific to alcohol withdrawal but can be seen in other conditions like opioid withdrawal.
In summary, the correct answer is D because increased heart rate and vomiting are commonly observed in alcohol withdrawal, while the other options do not align with typical symptoms of this condition.

Correct Answer: C

Rationale: The correct answer is C because relapses should be expected in the recovery process and seen as an opportunity for learning and growth. It is crucial for clients and families to understand that setbacks are a normal part of the journey towards sobriety. By viewing relapses as opportunities for reflection and adjustment, individuals can strengthen their coping strategies and enhance their resilience. This approach promotes a positive attitude towards setbacks and encourages continued progress.

Choices A, B, and D are incorrect because they promote negative beliefs about relapse, such as failure, lack of willpower, and rarity, which can be discouraging and unhelpful in the recovery process.

Correct Answer: B

Rationale: The correct answer is B: Speak softly to the client. This is the appropriate communication strategy as the nurse should create a safe and calming environment for the client. Speaking softly can help the client feel more comfortable and supported during a distressing time.

A: Asking open-ended questions about the perpetrator may trigger the client and lead to re-traumatization.
C: Providing direct eye contact may be perceived as intimidating or aggressive, making the client feel uncomfortable.
D: Sitting next to the client may invade their personal space and may not be desired by the client.

Correct Answer: A

Rationale: The correct answer is A: Allow the client to control the conversation. This approach empowers the client by giving them control over sharing their experience at their own pace, promoting trust and respect. Option B may be intrusive and re-traumatizing. Option C could pressure the client and compromise their autonomy. Option D, touching without consent, may trigger trauma responses. It is crucial to prioritize the client's emotional well-being and autonomy in such sensitive situations.