A client with borderline disorder tells the nurse, "It's hard to figure out who I am. Sometimes I'm sexually attracted to women and sometimes to men." The nurse using Freudian concepts can analyze this as a developmental problem related to:
1. Lack of separation-individuation
2. Isolation of affect during latency
3. Impaired development of sexual identity during the phallic stage
4. Overdevelopment of latency stage traits related to control issues
ANS: 3
According to Freud, identifying one's sexual identity takes place during the phallic stage of de-velopment. When sexual identity is not clearly established, the individual may express confusion in sexual preference. The other options do not relate to information given in the scenario.
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Which statement made by a nurse best indicates an understanding about the nurse's role in medication management for the older adult client?
1. "In the client with new onset constipation, I'll advocate for a daily laxative dose." 2. "When a client has difficulty sleeping, an as-needed dose of a benzodiazepine should be used." 3. "The client with acute pain should get pain medications around the clock and as needed." 4. "I should encourage the person with heartburn to sit up after medications and meals."
Prior to administering IV palonosetron, the nurse should:
a. flush the IV line with 0.9% saline. b. administer the other premedications. c. ask the client if he is allergic to serotonin. d. take the client's vital signs.
A client with a diagnosis of paranoid personality disorder appears hypervigilant and sits alone in an isolated area of the unit. The client does not acknowledge other clients and often uses sarcasm when addressing staff
The nurse invites the client to attend a milieu group, but the client ignores the nurse's efforts. An appropriate nursing diagnosis for this client is which of the following? A) Powerlessness B) Fear C) Activity intolerance D) Impaired social interaction
A nurse working in a long-term care facility has an elderly male client who is very confused. What ethical dilemma is posed when using restraints in a long-term care setting?
A) It limits personal safety. B) It increases confusion. C) It threatens autonomy. D) It prevents self-directed care.