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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.
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The LPN/LVN is caring for a client who was recently diagnosed with a mental illness. The client asks, 'Will I be able to live a normal life?' What is the best response for the nurse to provide?
- A. Yes, you will be able to live a normal life.
- B. Many people with mental illness lead full and productive lives.
- C. It will depend on your treatment and the choices you make.
- D. There is no normal; everyone is unique in their own way.
Correct Answer: C
Rationale: The best response for the nurse is to provide the client with hope while acknowledging the importance of their treatment and choices. Choice C addresses the client's concern by highlighting the impact of their treatment and personal choices on their future. It encourages personal responsibility and active participation in their recovery. Choices A and B may sound reassuring, but they do not empower the client to take an active role in their well-being. Choice D, while promoting individuality, does not directly address the client's question about living a normal life after a mental illness diagnosis.
A 19-year-old female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other clients on a psychiatric unit. What action should the nurse take?
- A. Encourage the client's self-motivation by asking her to assist with other activities.
- B. Provide an alternative suggestion for the client to participate in the unit's activities.
- C. Allow the client to serve dinner trays to other clients but monitor closely for any signs of distress.
- D. Explain to the client that she needs to focus on her own recovery and cannot participate in serving dinner trays.
Correct Answer: B
Rationale: Clients with anorexia should not be allowed to plan or prepare food for unit activities, as this can reinforce their perception of self-control. Allowing the client to serve dinner trays (C) may trigger distress or unhealthy behaviors. Therefore, it is best to provide an alternative suggestion for the client to participate in the unit's activities (B). Encouraging the client to assist with other activities (A) may inadvertently reinforce negative behaviors related to food. Explaining to the client that she cannot participate in serving dinner trays (D) without offering an alternative does not address the client's desire to help and may lead to feelings of rejection.
A client with schizophrenia is being treated with haloperidol (Haldol). The LPN/LVN observes the client pacing in the hallway and appearing anxious. What should the nurse do first?
- A. Ask the client to sit down and relax.
- B. Administer a PRN dose of antipsychotic medication.
- C. Encourage the client to talk about what is making him anxious.
- D. Monitor the client for adverse reactions to the medication.
Correct Answer: B
Rationale: Administering a PRN dose of antipsychotic medication is the first action the nurse should take to manage symptoms of anxiety in a client being treated with haloperidol. The priority is to address the client's escalating anxiety and pacing behavior, which can be managed effectively by providing additional antipsychotic medication. Asking the client to sit down and relax (Choice A) may not be effective if the anxiety is due to inadequate medication levels. Encouraging the client to talk about what is making him anxious (Choice C) may not be beneficial in this acute situation and can be considered after addressing the immediate need for symptom management. Monitoring for adverse reactions (Choice D) is important but is not the first action to take when the client is showing signs of increasing anxiety and agitation.
A client with schizophrenia is experiencing auditory hallucinations that command him to harm himself. What is the nurse's priority action?
- A. Ensure the client is not left alone.
- B. Document the content of the hallucinations.
- C. Administer PRN antipsychotic medication.
- D. Encourage the client to ignore the voices.
Correct Answer: A
Rationale: The correct answer is to ensure the client is not left alone. When a client with schizophrenia is having auditory hallucinations that command self-harm, the priority is to ensure the client's safety. Leaving the client alone may increase the risk of self-harm. Documenting the content of the hallucinations (choice B) is important but not the priority when immediate safety is a concern. Administering PRN antipsychotic medication (choice C) may be necessary but is not the priority over ensuring the client's immediate safety. Encouraging the client to ignore the voices (choice D) is not as effective as ensuring the client's safety by being present and providing support.
A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make?
- A. Did you really believe you were Jesus Christ?
- B. I think you're getting well.
- C. Others have had similar thoughts when under stress.
- D. Why did you think you were Jesus Christ?
Correct Answer: C
Rationale: Choice C is the best response because it validates the client's experience by acknowledging that others have had similar thoughts when under stress. This response helps normalize the client's past experiences without judgment, fostering a supportive and empathetic environment. Choices A and D may come off as judgmental or confrontational, potentially making the client feel misunderstood or defensive. Choice B, 'I think you're getting well,' does not address the client's past belief or provide the understanding and validation that Choice C offers.