After a period of unsuccessful treatment with Elavil (amitriptyline), a woman diagnosed with depression is switched to Parnate (tranylcypromine). Which statement by the client indicates the client understands the side effects of Parnate?
Rationale:
I must refrain from eating aged cheese or yeast products. This statement reflects an understanding of Parnate's dietary restrictions due to the risk of hypertensive crisis when consuming tyramine-rich foods like aged cheese and certain fermented products.
A: I must do increase my intake of sodium. Increasing sodium intake is not relevant to Parnate's side effects and does not address dietary restrictions necessary to avoid adverse reactions.
B: I must refrain from strenuous exercise. While exercise can be beneficial, this statement does not pertain to the critical dietary limitations associated with taking Parnate and managing its side effects.
D: I should decrease my intake of foods containing sugar. Sugar intake is not specifically linked to Parnate's side effects, making this statement unrelated to the critical dietary considerations for avoiding hypertensive crises.
A client is receiving paroxetine (Paxil) 20 mg every morning. After taking the first three doses, the client tells the nurse that the medication upsets his stomach. Which of the following instructions should the nurse give to the client?
Rationale:
Taking paroxetine with some food can help alleviate the stomach upset experienced by the client. Food can buffer the medication's effects on the gastrointestinal tract, potentially reducing nausea and discomfort during treatment.
A: Take the medication an hour before breakfast. This timing could exacerbate stomach upset, as taking medication on an empty stomach often leads to gastrointestinal irritation.
C: Take the medication at bedtime. While this may help with sleep issues, it does not address the stomach upset caused by the medication itself.
D: Take the medication with 4 oz of orange juice. Citrus juices can interact with certain medications, possibly increasing side effects or decreasing efficacy, which is not advisable in this situation.
The client with depression who is taking imipramine (Tofranil) states to the nurse, 'My doctor wants me to have an electrocardiogram (ECG) in 2 weeks, but my heart is fine.' Which response by the nurse is most appropriate?
Rationale:
It's routine practice to have ECGs periodically because there is a slight chance that the drug may affect the heart. This response acknowledges the potential risks associated with imipramine, emphasizing the importance of monitoring for any cardiac effects, which is crucial in managing the client's overall health and safety during treatment.
B: It's probably a precautionary measure because I'm not aware that you have a cardiac condition. This response lacks specificity about the drug's potential side effects and does not address the importance of ECG monitoring.
C: You don't need to worry about this. Your doctor is just being very thorough in monitoring your condition. This statement downplays the necessity of monitoring and fails to inform the client about the specific risks associated with imipramine.
D: You had an ECG before you were prescribed imipramine and the procedure will be the same. This response may confuse the client by implying that previous tests are sufficient without addressing the ongoing need for cardiac monitoring due to the medication.
A client states to a nurse, 'Hey sweetie, you're looking good today.' Which of the following responses by the nurse is best?
Rationale:
C: Please don't talk to me like that.
This response establishes professional boundaries while addressing the inappropriateness of the compliment. It reinforces the nurse's role and ensures the client understands the need for respectful communication in a healthcare setting.
A: Thank you for being so kind and thoughtful.
This response may encourage further inappropriate comments, undermining the professional relationship and potentially blurring the lines of appropriate communication in a clinical environment.
B: I know you are only teasing me.
Acknowledging the comment as teasing diminishes its seriousness, failing to assert the necessary professional boundaries that should exist between a nurse and a client in a healthcare context.
D: I am not here to receive compliments from clients.
This response is overly confrontational and may alienate the client, missing an opportunity to address the comment more tactfully while still maintaining the necessary professional boundaries.
A client will be discharged on lithium carbonate 600 mg three times daily. When teaching the client and his family about lithium therapy, the nurse determines that teaching has been effective if the client and family state that they will notify the prescribing health care provider immediately if which of the following occur? Select all that apply.
Rationale:
Clients on lithium therapy must be vigilant about symptoms indicating potential toxicity or serious side effects. Muscle weakness, vertigo, vomiting, and anorexia are significant signs warranting immediate medical attention, as they may indicate lithium levels are too high or other complications arise.
A: Nausea. This symptom is common in many treatments and may not signal a serious issue, thus not warranting urgent notification to the health care provider.
D: Fine hand tremor. While it can be a side effect of lithium, it is often benign and not an urgent sign of toxicity that requires immediate reporting.
The nursing assistant states to the nurse, 'My client talks about how awful and useless she is. Sometimes she sounds angry for no reason. I'm tired of listening to her.' Which of the following responses by the nurse is most appropriate?
Rationale:
It's important for you to listen to her because she needs to verbalize how she is feeling. This response emphasizes the significance of active listening and providing emotional support, which are essential components of effective nursing care for clients experiencing depression.
A: I'll switch your assignment to someone who's less depressed and less tiring. This response avoids addressing the client's needs and dismisses the assistant's concerns, failing to foster compassion or understanding.
C: Don't worry about it. I know you haven't done anything to make her angry. This trivializes the assistant's feelings and neglects the importance of recognizing the client's emotional struggles, undermining the therapeutic relationship.
D: Clients with depression are hard to deal with, but don't take what they say seriously. This promotes a dismissive attitude toward the client's experiences, which can lead to further isolation and does not support therapeutic engagement.
The nurse is teaching two nursing assistants who are new to the inpatient unit about caring for a client who is suicidal. The nurse determines that additional teaching is needed when which of the following statements is made?
Rationale:
A: I need to check the client precisely at 15-minute intervals. Checking at regular intervals is a standard practice for monitoring suicidal clients, ensuring their safety and timely intervention if needed.
B: Documenting suicide checks is absolutely necessary. Accurate documentation is vital in maintaining a clear record of observations and interventions, ensuring comprehensive care and accountability in managing suicidal clients.
C: A client on one-to-one suicide precautions can never be left alone. This statement reflects a misunderstanding; while close monitoring is crucial, it is possible for brief, supervised breaks to occur under specific circumstances.
D: All clients using razors must be supervised by staff. While supervision is essential for clients with potential self-harm risks, this statement overgeneralizes and does not consider individual assessment and context.
The nurse is conducting a quality improvement audit on the psychiatric unit. Which of the following findings indicates a need for corrective action?
Rationale:
A: A client with bipolar disorder has a serum lithium level drawn every 3 months. This practice aligns with clinical guidelines, ensuring appropriate monitoring of medication levels for safety and efficacy.
B: A client with suicidal ideation is checked every 15 minutes by staff. Frequent monitoring is a standard safety measure for clients at risk, demonstrating proper attention to their mental health needs.
C: A client with depression is allowed to keep a personal razor in their room. This poses a significant risk for self-harm, necessitating immediate corrective action to ensure patient safety and well-being.
D: A client with schizophrenia receives a daily dose of risperidone. Administering medication as prescribed is essential for managing symptoms, reflecting adherence to treatment protocols without indicating any need for intervention.
A client is becoming agitated during a discussion: 'The client is the same, “I know that the nurse.' She leaves the group and goes to her room. Which action by the nurse is most therapeutic for the client?
Rationale:
After group, ask the client to talk to the nurse about her concerns. This approach allows the client to express feelings in a safe environment, fostering trust and encouraging open communication, which is essential for therapeutic relationships.
B: Ask the client to return to group and share her feelings. This may pressure the client, potentially increasing her agitation instead of providing a supportive atmosphere for her to process emotions.
C: Explain to group members about the client's problems. Sharing the client's issues violates confidentiality, undermining trust and potentially increasing the client's distress rather than addressing her emotional needs compassionately.
D: Ask the group members to apologize to the client individually. While this may seem considerate, it could embarrass the client, leading to further withdrawal rather than promoting healing and understanding in a therapeutic setting.
When preparing the teaching plan for a client who is to start clozapine (Clozaril), which of the following is crucial to include?
Rationale:
The need for weekly blood tests is crucial when preparing the teaching plan for a client starting clozapine. This medication can cause agranulocytosis, a serious condition requiring regular monitoring of white blood cell counts to ensure patient safety and effective treatment management.
A: Description of akathisia and drug-induced parkinsonism. While understanding side effects is important, it does not encompass the critical need for blood monitoring associated with clozapine therapy.
B: Measures to relieve episodes of diarrhea. Although gastrointestinal side effects can occur, they are not as critical to address as the potential for life-threatening blood dyscrasias from clozapine use.
C: The importance of reporting insomnia. Insomnia may be a concern for some patients, but it does not carry the same immediate health risks as the necessity for regular blood testing during clozapine treatment.
As hospital-based care has become more oriented to crisis intervention, criteria for admission to the hospital have also changed. Which clients have priority for admission to an acute care facility? Select all that apply.
Rationale:
Clients who are acutely psychotic, acutely depressed, or dangerous to self or others have priority for admission to an acute care facility. These conditions represent severe mental health crises requiring immediate intervention for safety and stabilization.
A: Clients who live alone. Living alone does not inherently indicate a mental health crisis needing urgent care, and these individuals may not require hospitalization at this time.
E: Clients who are not sleeping and have a lack of appetite. While concerning, these symptoms alone do not necessitate acute care admission without accompanying severe psychiatric conditions or crises.
F: Clients who are not complying with medication regimens. Non-compliance may indicate a need for support but does not reflect an immediate crisis requiring hospitalization compared to other more acute conditions.
Which of the following should the nurse expect to include as a priority in the plan of care for a client with delirium based on the nurse's understanding about the disturbances in orientation associated with this disorder?
Rationale:
Identifying self and making sure that the nurse has the client's attention is essential in the care plan for a client with delirium. This approach aids in reorienting the client, enhancing communication, and establishing trust, which are crucial given their impaired perception and potential confusion regarding their surroundings and identity.
B: Eliminating the client's napping in the daytime as much as possible disrupts necessary rest and may exacerbate confusion, rather than providing effective orientation support and clarity.
C: Engaging the client in reminiscing with relatives or visitors may not address immediate orientation needs and could lead to further disorientation if the client struggles to recall past events.
D: Avoiding arguing with a suspicious client about his perceptions of reality is a valid de-escalation tactic, but it does not prioritize the immediate need for orientation and clarity in the care plan.
The nurse manager of a psychiatric unit notices that one of the nurses commonly avoids a 75-year-old client's company. Which of the following factors should the nurse manager identify as being the most likely cause of this nurse's discomfort with older clients?
Rationale:
The nurse commonly avoids the 75-year-old client's company due to fears and conflicts about aging.
This response reflects the common anxieties healthcare professionals may have regarding aging, which can manifest as discomfort in interactions with older clients. Such fears can stem from personal insecurities, societal stereotypes, or unresolved issues related to their own aging, leading to avoidance behaviors in the workplace.
B: Dislike of physical contact with older people. This option does not address the broader emotional and psychological factors that influence the nurse's avoidance behavior, focusing narrowly on physical interactions instead.
C: A desire to be surrounded by beauty and youth. This reasoning overlooks the complex dynamics of aging and interpersonal relationships, reducing the nurse’s behavior to superficial preferences rather than deeper psychological issues.
D: Recent experiences with her mother's elderly friends. While personal experiences can shape perceptions, this option does not directly connect to the nurse's professional role or her broader anxieties about aging.
A family member of a client with Alzheimer's disease asks, 'Why does she keep repeating herself?' What is the nurse's best response?
Rationale:
It's a common symptom due to memory loss. Repetition in Alzheimer's patients often stems from their cognitive decline, making it challenging for them to retain information, leading to frequent repetitions as they seek reassurance or connection.
A: She's trying to annoy you. This response misinterprets the behavior, attributing malice or intent where there is none, failing to acknowledge the underlying cognitive issues associated with Alzheimer's disease.
C: She needs more medication to stop this. Assuming medication is the solution overlooks the nature of Alzheimer's, where repetitive speech is a manifestation of the disease's progression rather than a treatable side effect.
D: You should correct her each time she repeats. Correcting a patient can lead to frustration or distress, which may worsen their anxiety and disrupt communication, ultimately hindering their emotional well-being.
A client with dementia refuses to take medication. What should the nurse do first?
Rationale:
C: Offer the medication in a liquid form. Providing the medication in a liquid format can enhance swallowability, ease administration, and may be more acceptable to a client with dementia, who may struggle with solid forms.
A: Crush the medication and mix it with food. Crushing medication can alter its effectiveness and safety, potentially leading to complications or adverse reactions that may harm the client.
B: Explain the medication's purpose. While education is important, a client with dementia may not comprehend or retain the explanation, making this approach less effective in facilitating medication acceptance.
D: Postpone administration until later. Delaying medication administration might inadvertently contribute to neglecting the client’s health needs, especially if the medication is essential for managing their condition effectively.
A client with paranoid schizophrenia is isolative. Which intervention is most effective?
Rationale:
Offering one-on-one activities is the most effective intervention for a client with paranoid schizophrenia who is isolative. This approach fosters a safe environment, allowing for personalized interaction that can reduce anxiety and build trust.
A: Force group participation. Compelling participation in group settings may increase feelings of paranoia and anxiety, exacerbating the client’s social withdrawal rather than promoting engagement.
C: Administer a PRN anxiolytic. While medication may alleviate acute anxiety, it does not address the underlying issues of isolation or promote meaningful social interaction essential for recovery.
D: Ignore the isolation. Neglecting the isolation can worsen the client’s mental state, as it fails to provide necessary support and intervention that encourages social connection and engagement.
The parents of a 20-year-old female client diagnosed with paranoid schizophrenia admitted 4 days ago are attending a family psychoeducation group in the hospital. Which of the following statements by the mother indicates that she understands her daughter's illness and management?
Rationale:
B: Tasks as simple as getting out of bed and showering in the morning may be difficult for her. This statement reflects an understanding of the challenges faced by individuals with paranoid schizophrenia, acknowledging that daily activities can be significantly impacted by the illness, which is crucial for effective management and support.
A: I know that I'll have to do everything for my daughter when she comes home. This perspective undermines her independence and does not promote her empowerment or recovery, which is essential for her well-being.
C: I know that visits from her friends at home should be discouraged for a while. This viewpoint lacks consideration for the positive effects of social support, which can be beneficial for her recovery and mental health.
D: She won't experience a relapse as long as she takes her prescribed medication. This statement is overly simplistic and ignores the multifaceted nature of mental health management, which involves various factors beyond just medication adherence.
A client diagnosed with schizophrenia is brought to the hospital from a group home where he became agitated, threw a chair at another client, and has been refusing medication for 8 weeks. The client exhibits a flat affect, is not caring for his hygiene, and has become increasingly withdrawn and asocial. The physician orders treatment with risperidone (Risperdal) to improve the client's negative and positive symptoms of schizophrenia. When evaluating the drug's effectiveness on the client's negative symptoms, the nurse should expect improvement in which of the following?
Rationale:
Improvement in apathy, lack of motivation, and asocial behavior is expected. Risperidone effectively targets negative symptoms of schizophrenia, enhancing emotional expression, social engagement, and self-care, which are crucial for the client's recovery.
B: Delusions, hallucinations. These symptoms are classified as positive symptoms of schizophrenia, which risperidone also addresses but are not the focus when evaluating negative symptoms improvement.
C: Hostility, ideas of reference, tangential speech. These behaviors relate to disorganized thinking and positive symptoms, which do not pertain to the client's negative symptoms that risperidone aims to improve.
D: Aggression, bizarre behavior, illusions. These manifestations are associated with severe positive symptoms of schizophrenia and are not indicative of the negative symptom improvements sought with risperidone treatment.
A client is complaining to other clients about not being allowed by staff to keep food in her room. The nurse should:
Rationale:
B: Setting limits on the behavior is essential for maintaining a respectful and therapeutic environment. The nurse must address the client's complaints while reinforcing the rules regarding food storage to ensure safety and hygiene.
A: Ignoring the client's behavior risks escalating the situation, as unresolved complaints may lead to further dissatisfaction among clients and disrupt the overall harmony of the facility.
C: Reprimanding the client could damage the therapeutic relationship and create an environment of fear or resentment, which is counterproductive to the supportive care the nurse should provide.
D: Allowing the snack to be kept in her room undermines established policies that prioritize safety and cleanliness, potentially leading to health risks and violating institutional regulations.
One evening the client takes the nurse aside and whispers, 'Don't tell anybody, but I'm going to call in a bomb threat to this hospital tonight.' Which of the following actions is the priority?
Rationale:
The priority action is explaining to the client that this information will have to be shared immediately with the staff and the physician.
This option is correct as it emphasizes the nurse's duty to ensure safety and communicate potential threats. By informing the staff and physician, the nurse can initiate appropriate safety protocols to protect everyone in the hospital from harm.
A: Warning the client that his telephone privileges will be taken away if he abuses them. This approach neglects the urgency of the threat and does not prioritize immediate safety measures required in such situations.
B: Offering to disregard the client's plan if he does not go through with it. This option minimizes the seriousness of the threat and fails to address the potential danger posed by the client's intention.
C: Notifying the proper authorities after saying nothing until the client has actually completed the call. This delayed response risks lives and allows the threat to escalate, compromising the safety of all individuals within the hospital.
The client is feeling better as the symptoms of alcohol withdrawal abate. She refuses information about alcohol rehabilitation and states, 'I don't have a problem. I'll never drink like that again. I learned my lesson this time. I guess I'll just have to switch to beer or wine.' The nurse should respond by:
Rationale:
C: Urging her to attend Alcoholics Anonymous meetings. Encouraging attendance at Alcoholics Anonymous is vital for individuals in recovery, particularly when they display denial about their drinking habits, as it provides supportive peers and coping strategies.
A: Discussing trouble. Merely discussing trouble may not address her denial effectively and could lead to defensiveness, preventing constructive dialogue about her alcohol use and the need for ongoing support.
B: Explaining the effects of drinking on her family. While family impacts are significant, focusing solely on this aspect may not resonate with her current mindset and could be perceived as judgmental.
D: Telling her about the physiologic damage that can result. Highlighting physiological damage might overwhelm her and distract from the crucial need for emotional and social support in her recovery journey.
The client sees no connection between her liver disorder and her alcohol intake. She believes that she drinks very little and that her family is making something out of nothing. The nurse interprets these behaviors as indicative of which of the following defense mechanisms?
Rationale:
Denial.
This behavior reflects a refusal to acknowledge the relationship between her liver disorder and alcohol consumption, demonstrating a protective mechanism against uncomfortable truths that could disrupt her self-perception and emotional state.
B: Displacement. This option suggests redirecting emotions towards a safer target, which does not apply here as she is not projecting feelings onto another person or object.
C: Rationalization. This choice implies justifying actions with plausible explanations. However, the client’s outright rejection of the connection indicates a lack of any justification process.
D: Reaction formation. This defense mechanism involves expressing the opposite of one's feelings. The client’s insistence on minimal drinking does not represent any contrary emotions or behaviors.
Which of the following should the nurse expect to assess for a client who is exhibiting late signs of heroin withdrawal?
Rationale:
Vomiting and diarrhea. Late signs of heroin withdrawal predominantly manifest through gastrointestinal distress, including nausea, vomiting, and diarrhea, indicating the body's severe reaction to the absence of the drug after prolonged use.
B: Yawning and diaphoresis. While yawning and diaphoresis may occur, they are typically observed during early withdrawal stages rather than late, where more severe symptoms dominate the clinical picture.
C: Lacrimation and rhinorrhea. Lacrimation and rhinorrhea are early withdrawal symptoms associated with opioid cessation, but they do not reflect the intensity of distress seen in late heroin withdrawal stages.
D: Restlessness and irritability. Although restlessness and irritability can occur, they are not definitive late signs; these symptoms often appear earlier in the withdrawal process and lessen as withdrawal progresses.
The client is fidgeting and has trouble sitting still. He has difficulty concentrating and is tangential. Which of the following interventions should help manage this client's level of anxiety? Select all that apply.
Rationale:
Refocusing attention, suggesting a time-out, and assisting with problem solving are effective interventions to manage the client's anxiety. These strategies help redirect the client's thoughts, provide a calming break, and promote active engagement in addressing concerns.
B: Allowing ventilation. This option does not directly address the client's anxiety symptoms and may not provide the necessary structure or focus needed for improvement.
D: Giving intramuscular medication. While medication can help in certain situations, it does not facilitate immediate coping strategies or behavioral interventions that the client may require.
Which of the following statements by a client who has been taking buspirone (BuSpar) as prescribed for 2 days indicates the need for further teaching?
Rationale:
This medication will help my tight, aching muscles. This statement indicates misunderstanding, as buspirone primarily targets anxiety and does not directly relieve muscle tension or pain, necessitating further education on its effects.
B: I may not feel better for 7 to 10 days. This statement accurately reflects the delayed therapeutic effects of buspirone, aligning with patient expectations regarding the timeline for experiencing benefits.
C: The drug does not cause physical dependence. This conveys a correct understanding, as buspirone is not associated with physical dependence, differentiating it from some other anxiolytics that carry that risk.
D: I can take the medication with food. This statement is valid, as buspirone can be taken with food to enhance absorption and minimize gastrointestinal side effects, reflecting proper usage.
Which of the following statements indicates to the nurse that the client is progressing toward recovery from a somatoform disorder?
Rationale:
I understand my pain will feel worse when I'm worried about my divorce. This statement reflects the client's awareness of the connection between emotional stress and physical symptoms, indicating improved insight and coping, which are crucial for recovery from a somatoform disorder.
B: My stomach pain will go away once I get properly diagnosed. This reveals a reliance on external validation rather than personal understanding, suggesting limited progress in addressing the psychological components of the disorder.
C: My headache feels better when I time my medication dose. This indicates a focus on pharmacological management rather than recognizing the psychological influences on symptoms, which does not demonstrate meaningful progress in recovery.
D: I need to find a doctor who understands what my pain is like. This reflects a search for external support rather than an internal recognition of the disorder's psychological dimensions, indicating stagnation in personal insight.
A client commonly jumps when spoken to and reports feeling uneasy. The client says, 'It's as though something bad is going to happen.' In which order from first to last should the following nursing actions be done?
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Teach problem solving strategies.
B
Ask the client to deep breathe for 2 minutes.
C
Discuss the client's feelings in more depth.
D
Reduce environmental stimuli.
Rationale:
D: Reducing environmental stimuli creates a calmer atmosphere, allowing the client to feel more secure and less anxious. This foundational step is essential before addressing deeper issues or coping strategies.
A: Teaching problem-solving strategies requires a sense of safety and focus, which may not be present until the client's anxiety is initially addressed through environmental adjustments.
B: Engaging the client in deep breathing provides immediate relief, yet it is more effective once the surrounding stressors are minimized to enhance the calming effects.
C: Discussing the client's feelings is crucial for therapeutic progress but should occur after establishing a safe environment and calming the client's immediate anxiety to foster open communication.
When coping becomes dysfunctional enough to require the client to be admitted to the hospital, the nurse should assess the client for the ability to demonstrate which of the following?
Rationale:
D: Minimal functioning with new problems developing. This answer is appropriate as it highlights the critical need to assess a client's capability to manage ongoing challenges effectively, especially when they are facing severe dysfunction that necessitates hospitalization. Recognizing minimal functioning indicates a deterioration in coping mechanisms, warranting immediate intervention.
A: Objective and rational problem solving. This option overlooks the immediate assessment of the client’s functionality, focusing instead on rationality, which may not be present during a crisis.
B: Tension reduction activities and then problem solving. While tension reduction is important, it does not address the client’s current level of functioning or their ability to cope with emerging issues.
C: Anger management strategies with no problem solving. This choice emphasizes managing emotions without considering the broader context of the client’s overall functioning and their ability to tackle new challenges effectively.
The nurse should determine that a client lacks understanding of her acute cardiac illness and the ability to make changes in her lifestyle by which of the following statements?
Rationale:
I already have my airline ticket, so I won't miss my meeting tomorrow. This statement indicates a prioritization of commitments over health concerns, suggesting a lack of understanding about the seriousness of her cardiac condition and necessary lifestyle changes.
B: These relaxation tapes sound okay; I'll see if they help me. This reflects a willingness to explore options for managing stress, indicating some understanding of the need for lifestyle adjustments.
C: No more working 10 hours a day for me unless it's an emergency. This statement shows recognition of the need to limit work hours, demonstrating awareness of the importance of balancing stress and health.
D: I talked with my husband yesterday about working on a new budget together. This reveals proactive engagement in financial planning, suggesting the client is considering lifestyle changes that will positively impact her health.
The nurse is advising a client with schizophrenia about what to do when she begins to get agitated. The client has been compliant with taking her medications and has worked with clinic staff on dealing with her illness and recognizing when she is becoming agitated. Indicate the order from first to last the nurse should suggest the following actions be taken.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Take your oral lorazepam (Ativan).
B
Take your oral haloperidol (Haldol).
C
Remove yourself to a quiet environment.
D
Tell trusted people that you are becoming upset.
Rationale:
Remove yourself to a quiet environment. This action is crucial as it allows the client to regain composure and reduces stimuli that may exacerbate agitation, creating a more therapeutic atmosphere for recovery.
A: Take your oral lorazepam (Ativan). Administering medication should come after implementing non-pharmacological strategies, as calming techniques may be sufficient before resorting to medication.
B: Take your oral haloperidol (Haldol). Antipsychotic medication is typically reserved for more severe symptoms and should not be the first action in addressing early signs of agitation.
D: Tell trusted people that you are becoming upset. While communication is important, it is more effective to first seek personal calmness before discussing feelings of agitation with others.
A client is being discharged after 3 days of hospitalization for a suicide attempt that followed the loss of a job. Which of the following should be the nurse's priority action before discharge?
Rationale:
Ensure the client has a follow-up appointment with a mental health provider. This action is vital as it establishes ongoing support and treatment, significantly reducing the risk of further suicide attempts after discharge.
A: Increase the client's antidepressant dosage. Adjusting medication without thorough evaluation can lead to adverse effects and is not the immediate priority for discharge planning.
B: Provide a list of community support groups. While helpful, simply providing resources does not ensure that the client has a structured, professional follow-up, which is essential for safety.
D: Instruct the client to avoid all work-related activities for a month. Restricting work without considering the client's overall recovery plan may contribute to feelings of isolation and dependency, rather than promoting healing.
A client with a history of angry outbursts is learning to identify triggers. Which activity should the nurse recommend?
Rationale:
Keeping a journal of anger-provoking situations. This activity encourages self-reflection, allowing the client to pinpoint specific triggers, understand emotional responses, and develop strategies to manage anger effectively in future encounters.
B: Practicing yoga daily to reduce tension. While beneficial for overall stress management, yoga does not specifically address identifying or understanding the client’s unique anger triggers and their contexts.
C: Avoiding all stressful environments. This approach may not be practical or effective long-term, as it prevents the client from learning how to cope with and manage anger in various situations.
D: Taking a walk when feeling calm. Although walking can be a healthy outlet, it does not assist the client in recognizing or analyzing the situations that lead to anger outbursts.
During the third session with the nurse, a client who is being abused states, 'I don't know what to do anymore. He doesn't want me to go anywhere while he's at work, not even to visit my friends.' Which nursing diagnosis should the nurse formulate regarding this information?
Rationale:
Powerlessness related to control by husband, as evidenced by the inability to make decisions. The client's statement reflects a significant lack of autonomy, indicating that the husband exerts control over her actions and choices, leading to feelings of helplessness and powerlessness in her situation.
A: Risk for other-directed violence related to an abusive husband, as evidenced by the victim's statement of being battered. This option focuses on potential harm to others rather than the client's current experience of control and powerlessness.
B: Situational low self-esteem related to victimization, as evidenced by not being able to leave the house. Although low self-esteem may be present, the primary issue highlighted is the loss of control, not self-worth.
D: Ineffective coping related to victimization, as evidenced by crying. While the client may be struggling to cope, the primary concern is her inability to make decisions and lack of control over her life.
The nurse discovers that an adolescent client with anorexia nervosa is taking diet pills rather than complying with the diet. What should the nurse do first?
Rationale:
Listen to the client about fears of losing control of eating while being treated.
This option prioritizes establishing a therapeutic relationship, allowing the nurse to understand the client's emotional state. Addressing the client's fears directly can foster trust, encourage open communication, and ultimately facilitate adherence to treatment while exploring underlying issues related to anorexia nervosa.
A: Explain to the client how diet pills can jeopardize health. This approach may alienate the client, as it focuses on consequences rather than understanding their emotional concerns, potentially hindering communication and trust.
C: Talk with the client about how weight loss and emaciation worry the health care providers. Centering the discussion on providers’ worries diverts attention from the client’s personal experiences, which may not resonate with their feelings or fears.
D: Inquire about the client's family's worries concerning the client's physical and emotional health. This option shifts focus away from the client’s perspective, neglecting the importance of addressing their individual feelings and fears first, which is crucial for effective care.
The nurse is assessing a 7-year-old boy with Tourette syndrome. Which of the following is a priority for the nurse to assess?
Rationale:
Multiple motor and verbal tics. Assessing both motor and verbal tics is essential as Tourette syndrome commonly presents with a combination of symptoms, impacting the child's social interactions and overall well-being.
B: Primarily motor tics. Focusing solely on motor tics overlooks the critical verbal aspects that can significantly affect the child's communication and emotional health.
C: Isolated verbal tics. Concentrating on only verbal tics neglects the essential assessment of motor tics, which frequently co-occur and can influence daily functioning.
D: Alternating simple and complex motor tics. While important, this option does not encompass the necessity to assess both motor and verbal tics that are central to Tourette syndrome.
A nurse is counseling a client who has experienced domestic abuse for several years. The client expresses fear of leaving the abuser due to financial dependence. What is the nurse's priority intervention?
Rationale:
Provide information about local shelters and resources.
Access to safe shelters and supportive resources is essential for individuals fearing domestic abuse, as it empowers them to make informed decisions and consider leaving the abusive environment without feeling financially trapped.
A: Refer the client to a financial advisor. Financial advice may not address the immediate safety concerns and emotional distress, which are paramount in situations of domestic abuse and should be prioritized first.
C: Encourage the client to confront the abuser about her fears. Confrontation could escalate the situation, increasing the risk of danger for the client, rather than providing a safe pathway to leave.
D: Teach the client stress management techniques. While stress management is beneficial, it does not directly address the critical need for safety and support resources essential for escaping domestic abuse situations.
A client newly diagnosed with bulimia is attending the nurse-led group at the mental health center. She tells the group that she came only because her husband said he would divorce her if she didn't get help. Which of the following responses by the nurse is appropriate?
Rationale:
C: "Tell me more about why you are here and how you feel about that." This response invites the client to express her feelings and motivations, fostering a supportive environment that encourages open dialogue and reflection on her situation, which is crucial for her treatment and understanding of her condition.
A: "You sound angry with your husband. Is that correct?" This response focuses too much on the client’s emotions towards her husband rather than exploring her feelings about her diagnosis and treatment.
B: "You will find that you like coming to group. These people are a lot of fun." This option minimizes the seriousness of her situation and does not address her underlying feelings or concerns, potentially diminishing her willingness to engage.
D: "Tell me something about what has caused you to be bulimic." This approach shifts focus to her condition rather than her current feelings and motivations for attending the group, which may hinder her emotional expression.
The nurse is performing an admission assessment on a client admitted to the behavioral health unit. The client is reporting new-onset blindness after witnessing a traumatic motor vehicle accident. The nurse suspects that this client is using which defense mechanism?
Rationale:
New-onset blindness after a traumatic event suggests the client is using conversion. This defense mechanism manifests as physical symptoms, such as blindness, in response to psychological distress stemming from trauma.
A: suppression This involves consciously ignoring distressing thoughts or feelings, rather than exhibiting physical symptoms. The client’s blindness is not a choice to forget but a physical response to trauma.
C: displacement This involves redirecting emotions to a safer target, but the client's blindness does not reflect a shift of feelings. It represents a physical manifestation tied to the traumatic experience.
D: dissociation This involves a disconnection from thoughts or emotions, yet the client's blindness is a tangible symptom. It indicates a physical expression of psychological conflict rather than a mental detachment.
The nurse is caring for a client who is struggling with severe depression. Which of the following statements would demonstrate effective therapeutic communication with this client? Select all that apply.
Rationale:
B: I'd like to just sit with you for a while Steve. This statement reflects a non-intrusive, supportive approach, offering presence and comfort, which is crucial for clients experiencing severe depression. It fosters connection without pressure.
C: Tell me how you're feeling Steve. I'd like to understand. This inquiry encourages open dialogue, demonstrating genuine interest in the client's emotions, thus facilitating a safe space for sharing and healing.
A: Great work today in group therapy Steve, you were really talkative today! This statement may come off as superficial or dismissive, focusing on behavior rather than addressing the client's emotional state.
D: Why are you feeling depressed today Steve? This question may inadvertently pressure the client to justify their feelings, which can hinder open communication and may lead to defensiveness instead of support.
E: I know exactly how you feel. I've been through the same thing. This statement could diminish the client’s unique experience, suggesting a comparison that may feel invalidating rather than empathetic.
The following scenario applies to the next 6 items
The nurse in the behavioral health clinic is caring for a 26-year-old female client.
Item 5 of 6
Nurses' Note
1025: Client presents for initial evaluation, reporting that she “feels all over the place and it is time that she receives some treatment.†“At times I feel empty inside, sometimes feel hyped up, and at times, like now, I feel sadâ€. On assessment, the client has a constricted affect, and her eyes were cast downward. Client reports that her depression has been present for as long as she can remember, including throughout grade school. Her first clearly recalled depressive episode occurred in the sixth grade, when she felt she was "not living up to my own expectations." These episodes varied in duration—some lasting several months, others only a few hours—but typically persisted for 2 to 4 weeks. Onset could range from a day to a week, while the offset was often abrupt, resolving within a day or less. She reported intermittent difficulty falling asleep. Lately, she has had to use 2-3 tablets of diphenhydramine to help her fall asleep. She denied experiencing racing thoughts but acknowledged being told on numerous occasions that she spoke in ways that felt ‘pressured.’ She also endorsed distractibility and noted frequent difficulty completing tasks. During times of good mood or when she felt "aligned with others,†she found herself more productive, particularly in creative endeavors. However, at other times, even simple tasks felt overwhelming. She described experiencing "a flurry of thoughts," particularly while writing or during creative projects. At age 23, she experienced what she referred to as "an explosive outburst of rage," which culminated in her punching a hole in her roommate’s car's windshield. She reports this occurred during a two-day ‘episode’ of her being irritable. Medical history of tension headaches, mild eczema in winter months, and seasonal allergic rhinitis. The client consumes 1-2 glasses of alcohol a year. She does smoke cigarettes daily and started smoking when she was 20.
Orders
1130:
• lamotrigine 25 mg p.o. daily
• follow-up in two weeks
• obtain thyroid panel
• trazodone 50 mg p.o. at bedtime
• discontinue diphenhydramine
It is essential that the nurse educates the client to while taking lamotrigine.
Rationale:
B: report flu-like symptoms. Lamotrigine can cause serious skin rashes and other side effects, including flu-like symptoms that may indicate an adverse reaction. Early reporting of such symptoms is crucial for the client’s safety.
A: avoid dehydration. While hydration is important, it is not specifically related to lamotrigine use and does not directly impact the medication's effectiveness or potential side effects.
C: wear a surgical mask in public. There is no indication in the context that lamotrigine requires such precautions. This advice does not correlate with the medication’s known side effects.
D: consume a consistent amount of salt. Salt intake does not have a direct connection to lamotrigine therapy. This option does not address the specific monitoring required for this medication.
The nurse is caring for a client with a terminal illness. The client states, 'Lord, just give me two more months so I can go to my grandson's wedding.' The nurse interprets this statement as
Rationale:
The client’s request for additional time reflects a desire to negotiate with fate, a hallmark of the bargaining stage in grief. This stage often involves attempts to regain control over an uncontrollable situation, illustrating the client's emotional struggle.
B: depression. The statement does not convey hopelessness or profound sadness, which are typical indicators of depression, but rather a hopeful plea for more time.
C: anger. There is no expression of frustration or resentment in the client's statement; instead, it demonstrates a longing for connection and closure, characteristic of bargaining.
D: denial. The request does not indicate disbelief about the terminal condition but rather a wish to prolong life for a specific meaningful event, aligning with bargaining rather than denial.
A nurse is caring for a child who has autism. Which of the following actions should the nurse take? Select all that apply.
Rationale:
B: Having a family member bring in the child's favorite toys creates a sense of familiarity and comfort, which is crucial for reducing anxiety and enhancing communication with autistic children.
C: Dimming the lights in the room helps minimize sensory overload, promoting a calmer environment that can support the child's emotional well-being and focus.
E: Maintaining consistent caregivers fosters trust and security, essential for children with autism as they thrive on routine and familiarity in their healthcare interactions.
A: Withholding prescribed vaccines poses significant health risks, undermining the necessity of vaccinations for all children, including those with autism.
D: Secluding the child for any misconduct may exacerbate feelings of isolation and fear, counteracting the supportive environment needed for effective care and behavioral management.
The nurse is caring for a client who has bipolar disorder and is experiencing acute mania. Which of the following actions should be prioritized by the nurse?
Rationale:
C: Provide high-calorie, small, frequent meals. Prioritizing nutrition is essential during acute mania, as clients often neglect food intake due to their heightened energy levels and distractibility. Ensuring adequate nourishment helps stabilize mood and supports overall health during this critical period.
A: Plan structured solitary activities. While structure can be beneficial, solitary activities may exacerbate feelings of isolation and are less effective during acute mania when social interaction can help manage symptoms.
B: Redirect the client's speech and ideas. Although redirection is useful, it does not address immediate physical needs like nutrition, which is vital for maintaining energy and health during mania.
D: Initiate a psychiatry referral. Referral can be necessary later, but immediate nursing actions, such as ensuring proper nutrition, take precedence in managing the acute phase of mania effectively.
The nurse in the mental health clinic is performing an assessment on a client with a history of major depressive disorder and is taking prescribed medications. The client reports feeling hopeless, has withdrawn from his usual activities, and states, 'I just don't see the point anymore.' When asked about suicidal thoughts, he admits to thinking about death frequently but denies having a plan. Based on this information, the nurse should initially
Rationale:
Conduct a more detailed suicide risk assessment, including intent and means. This is crucial given the client’s admission of frequent thoughts of death, which indicates a potential risk for self-harm or suicide. A comprehensive evaluation will inform the best immediate actions to ensure the client's safety.
A: Reassure the client and arrange for a follow-up appointment in two weeks. This approach does not address the immediate risk posed by the client's suicidal thoughts, which require urgent evaluation.
B: Determine if the client has adhered to his prescribed medications. While medication adherence is important, the immediate focus should be on the client's current mental state and suicidal ideation, not his medication compliance.
D: Notify the physician and recommend involuntary admission. This action may be premature without first conducting a detailed suicide risk assessment to fully understand the client’s situation and needs.
The nurse is caring for an involuntarily admitted client with an order for electroconvulsive therapy (ECT). Before transferring the client to the procedure room, the nurse notes that the consent form is unsigned. The nurse understands that
Rationale:
Informed consent needs to be obtained from the court. Involuntarily admitted clients may lack the capacity to consent, thus requiring judicial approval for procedures like ECT to ensure legal and ethical standards are upheld.
A: Informed consent should be obtained from the client's spouse. Spousal consent does not suffice when the client is involuntarily admitted; legal authority must come from the court instead.
B: Informed consent should be obtained from the client. Involuntarily admitted individuals may not demonstrate the capacity to provide valid consent, necessitating court involvement for such procedures.
C: Informed consent is not required. Court approval is essential in cases involving involuntary admission, as it addresses the legal complexities surrounding the client's ability to consent.
Which form of therapy would most likely be used to treat a group of clients affected by phobias?
Rationale:
Cognitive behavioral psychotherapy is the most likely form of therapy to treat a group of clients affected by phobias.
This approach effectively addresses phobias by combining cognitive restructuring and behavioral techniques, enabling clients to confront and modify their irrational fears. It emphasizes practical strategies and gradual exposure, making it particularly suitable for group settings where shared experiences can enhance learning and coping mechanisms.
A: Behavioral psychotherapy focuses primarily on modifying behaviors without deeply addressing the underlying thought patterns, which are crucial for effectively treating phobias.
C: Psychoanalysis delves into unconscious motivations and childhood experiences, making it less effective for the immediate treatment of phobias, which require more practical and direct interventions.
D: Cognitive psychotherapy centers on changing unhelpful thoughts, but lacks the behavioral components essential for exposure techniques that are particularly beneficial in addressing phobic responses.
The clinic nurse notices bruising at multiple stages of healing on a two-year-old. The nurse also sees two burns on the toddler's trunk. What would be the most appropriate action for the nurse to take?
Rationale:
Call the local authorities or the designated state-specific child abuse hotline.
Reporting suspected child abuse is crucial when observing signs like bruising and burns, especially in a toddler. The child's safety is paramount, and professional intervention is necessary to ensure proper investigation and protection of the child from potential harm.
A: Confront the child's parent(s)/caregiver(s) Engaging directly with parents may escalate the situation and jeopardize the child's safety, delaying necessary intervention and failing to provide immediate protection for the child.
C: Recheck the child after two weeks Waiting two weeks to reassess the child ignores immediate safety concerns and risks further harm, as urgent action is essential in suspected abuse cases.
D: Call the health care provider (HCP) While consultation is important, it does not address the immediate need to report suspected abuse to authorities, potentially leaving the child in an unsafe environment.
The nurse discusses the signs and symptoms of child abuse at an interprofessional conference. It would be correct for the nurse to identify which manifestations are associated with physical abuse? Select all that apply.
Rationale:
Spiral fractures without any sports injury, scalded burns on legs, and bruises without plausible explanation are manifestations associated with physical abuse. These signs indicate potential non-accidental harm, warranting further investigation.
A: Verbal assault does not relate specifically to physical manifestations; it pertains to emotional or psychological abuse rather than physical injuries.
B: Sexual contact between legal parent/guardian does not indicate physical abuse; it represents a form of sexual abuse and is unrelated to physical injury signs.
The nurse is reviewing the laboratory report with the client's lithium level taken that morning prior to administering the 5 p.m. dose of lithium. The lithium level is 1.8 mEq/L. The nurse should:
Rationale:
Hold the 5 p.m. dose of lithium. The lithium level of 1.8 mEq/L exceeds the therapeutic range of 0.6 to 1.2 mEq/L, indicating a risk of toxicity. Immediate intervention is necessary to prevent adverse effects.
A: Administer the 5 p.m. dose of lithium. This action would exacerbate the risk of lithium toxicity, given the elevated serum level already present in the client's bloodstream.
C: Give the client 8 oz (236 mL) of water with the lithium. While hydration is important, this does not address the elevated lithium level and could inadvertently increase toxicity.
D: Give the lithium after the client's supper. Delaying administration does not mitigate the dangerously high lithium level, which requires immediate assessment and action to ensure the client’s safety.