Nokea
A young adult female client is admitted to a psychiatric facility with a medical diagnosis of bulimia nervosa. Which nursing intervention has the highest priority?
- A. Schedule the client for group therapy with other clients with bulimia nervosa.
- B. Assign the client's care to a nurse with relevant experience in eating disorders.
- C. Monitor the client carefully for binging and purging activities.
- D. Assess and report the client's electrolyte status to the healthcare provider.
Correct Answer: D
Rationale: The correct answer is D. Assessing and reporting the client's electrolyte status to the healthcare provider is the highest priority in a client with bulimia nervosa. Electrolyte imbalances, such as hypokalemia and metabolic alkalosis, are common due to purging behaviors associated with bulimia. Monitoring electrolyte levels is crucial to prevent life-threatening complications. Choices A, B, and C are incorrect because while therapy and monitoring for binging activities are important, addressing the electrolyte imbalances caused by purging behaviors takes precedence in the immediate care of a client with bulimia nervosa.
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A female client with borderline personality disorder expresses fear of being abandoned by the nursing staff. What is the best nursing intervention?
- A. Reassure the client that she will not be abandoned.
- B. Set limits on the client's behavior and enforce them consistently.
- C. Encourage the client to talk about her fears.
- D. Rotate the nursing staff assigned to the client frequently.
Correct Answer: B
Rationale: The best nursing intervention for a client with borderline personality disorder expressing fear of abandonment is to set limits on the client's behavior and enforce them consistently. This approach helps establish boundaries and provides a sense of security for the client. Choice A may provide temporary reassurance but does not address the core issue or help the client develop coping strategies. Choice C is important but should be accompanied by setting limits to address the underlying fear of abandonment. Choice D of rotating staff frequently can exacerbate the client's fear of abandonment by reinforcing the idea of being left.
A nurse is caring for a client who is experiencing severe anxiety. Which intervention is most appropriate for the nurse to implement?
- A. Instruct the client to take deep breaths and focus on the present.
- B. Encourage the client to discuss their fears in detail.
- C. Distract the client with a humorous story or anecdote.
- D. Leave the client alone to process their emotions.
Correct Answer: A
Rationale: The correct intervention for a client experiencing severe anxiety is to instruct the client to take deep breaths and focus on the present. Deep breathing can help reduce the physiological symptoms of anxiety and provide the client with a way to regain control over their emotions. Choice B is incorrect as discussing fears in detail may escalate anxiety levels. Choice C is inappropriate as distracting the client may not address the root cause of anxiety. Choice D is not recommended as leaving the client alone can increase feelings of isolation and distress.
A client who has recently been diagnosed with schizophrenia tells the LPN/LVN, 'I hear voices telling me to hurt myself.' What is the most appropriate nursing action?
- A. Encourage the client to ignore the voices.
- B. Tell the client that the voices will go away with medication.
- C. Monitor the client for signs of self-harm.
- D. Refer the client for a psychiatric evaluation.
Correct Answer: D
Rationale: The correct answer is to refer the client for a psychiatric evaluation. The client's statement indicating hearing voices telling them to hurt themselves is a serious concern and suggests a risk for self-harm. Referring the client for a psychiatric evaluation is crucial for further assessment and intervention by mental health professionals. Choice A is incorrect because ignoring the voices may not address the client's safety. Choice B is incorrect as it oversimplifies the situation and does not address the immediate risk. Choice C is not as comprehensive as referring for a psychiatric evaluation, which is necessary in this situation.
A 35-year-old male client on the psychiatric unit of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to his
- A. early childhood experiences involving authority issues.
- B. anger about being hospitalized.
- C. low self-esteem.
- D. phobic fear of food.
Correct Answer: C
Rationale: Psychotic clients often experience delusions due to difficulties with trust and low self-esteem (C). In this case, the client's belief that someone is trying to poison him is likely a manifestation of his underlying issues with trust and self-worth. Building trust and promoting positive self-esteem are essential in caring for such clients. Choices A, B, and D are incorrect because delusions are not primarily related to early childhood experiences involving authority issues, anger about hospitalization, or phobic fear of food. These factors do not directly contribute to the development of delusions in psychotic clients.
A client in the mental health unit believes that the food is being poisoned. What intervention(s) would be helpful when attempting to encourage the client to eat? Select one that does not apply.
- A. Use open-ended questions to encourage client dialogue
- B. Offer opinions about the necessity for adequate nutrition
- C. Focus on the client's self-disclosure about food preferences
- D. Identify the reasons the client has for not wanting to eat
Correct Answer: B
Rationale: Using open-ended questions and focusing on the client's self-disclosure about food preferences can help build rapport and trust with the client, encouraging them to eat. Identifying the reasons the client has for not wanting to eat can provide insights into their concerns. However, offering opinions about the necessity for adequate nutrition may come across as imposing views on the client, potentially leading to resistance. This approach may not be as effective in encouraging the client to eat as it could create a power dynamic that hinders the therapeutic relationship.