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A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the deceased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time?
- A. Not sleeping for several days.
- B. Wishing to be with spouse.
- C. Lack of interest in usual activities.
- D. Eating very little.
Correct Answer: A
Rationale: The correct answer is A: Not sleeping for several days. This is the most important client statement to explore because it indicates the client may be experiencing severe sleep disturbances, which can have a significant impact on their mental and physical health. Lack of sleep can exacerbate symptoms of depression and increase the risk of self-harm or suicide. Therefore, the RN should prioritize exploring this issue to assess the client's safety and provide appropriate interventions.
Choices B, C, and D are also important concerns related to grief and depression, but the immediate risk associated with severe sleep deprivation makes option A the most critical to address first. It is essential to address all client statements eventually, but the urgency of the client's sleep disturbances requires immediate attention.
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Which characteristic in an adolescent female is sometimes associated with the prodromal phase of schizophrenia?
- A. Always afraid another student will steal her belongings.
- B. An unusual interest in numbers and specific topics.
- C. Demonstrates no interest in athletics or organized sports.
- D. Appears more comfortable among males.
Correct Answer: A
Rationale: The correct answer is A because paranoia and irrational fear can be early signs of prodromal phase of schizophrenia. This can manifest as the constant fear of belongings being stolen. Choice B is incorrect as it suggests autistic traits, not specific to schizophrenia. Choice C is incorrect as lack of interest in sports is not directly linked to schizophrenia. Choice D is incorrect as comfort among males is not a defining characteristic of the prodromal phase of schizophrenia.
An antidepressant medication is prescribed for a client who reports sleeping only 4 hours in the past 2 days and weight loss of 9 lbs within the last month. Which client goal is most important to achieve within the first three days of treatment?
- A. Meet scheduled appointment with dietitian.
- B. Sleep at least 6 hours a night.
- C. Understands the purpose of the medication regimen.
- D. Describes the reasons for hospitalization.
Correct Answer: B
Rationale: The correct answer is B: Sleep at least 6 hours a night. Adequate sleep is crucial in the management of depression as it can improve mood, cognition, and overall functioning. Lack of sleep can exacerbate depressive symptoms. Addressing sleep disturbance early can lead to an improvement in the client's overall well-being. Meeting with a dietitian (choice A) may be important for addressing weight loss but is not as urgent as improving sleep. Understanding the purpose of the medication regimen (choice C) is important for long-term treatment adherence but may not be the priority within the first three days. Describing the reasons for hospitalization (choice D) is not directly related to the immediate treatment goal of addressing sleep disturbance.
During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process?
- A. Assist the client in developing alternative coping skills.
- B. Remain calm and use a matter of fact approach.
- C. Ask the client why she is so anxious
- D. Administer a PRN sedative to help relieve her anxiety.
Correct Answer: B
Rationale: The correct answer is B: Remain calm and use a matter-of-fact approach. This approach is essential to provide a sense of safety and security for the client experiencing extreme anxiety. By remaining calm, the nurse can model a calming presence and help the client feel more at ease. Using a matter-of-fact approach can help normalize the situation and reassure the client that her feelings are valid but manageable.
A: Assisting the client in developing coping skills may be beneficial in the long term, but in this acute situation, the immediate focus should be on providing immediate support.
C: Asking the client why she is anxious may not be helpful as it can potentially increase her anxiety or lead to a delusional explanation.
D: Administering a sedative should not be the first intervention as it does not address the underlying cause of the anxiety and may mask important information that could help in providing appropriate care.
In summary, the most important intervention is remaining calm and using a matter-of-fact
During an admission assessment and interview, which channels of information communication should the nurse be monitoring? Select all that apply.
- A. Auditory
- B. Visual
- C. Written
- D. Tactile
Correct Answer: A
Rationale: The correct answer is A: Auditory. During an admission assessment and interview, monitoring auditory communication channels is crucial for gathering information through spoken words, tone, and non-verbal cues like sighs or hesitations. This helps the nurse assess the patient's mental state, emotions, and communication effectiveness. Visual (B), written (C), and tactile (D) channels are not typically monitored during a standard interview, as they may not provide relevant information for the assessment process. Visual cues like body language can be important but are not as essential as auditory cues in this context. Written communication is not typically used in a face-to-face interview, and tactile communication is usually unnecessary unless specific procedures are being performed.
The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued?
- A. Alprazolam (Xanax)
- B. Benztropine (Cogentin)
- C. Magnesium (Milk of Magnesia)
- D. Lithium (Lithotabs)
Correct Answer: B
Rationale: The correct answer is B: Benztropine (Cogentin). Benztropine is a medication commonly used to treat extrapyramidal side effects caused by antipsychotic medications. If the antipsychotic medication is discontinued, there is no longer a need for Benztropine. Alprazolam (A) is used to treat anxiety and should not be automatically discontinued. Magnesium (C) is a laxative and unrelated to bipolar disorder treatment. Lithium (D) is a mood stabilizer commonly used in bipolar disorder treatment and should not be discontinued without a healthcare provider's guidance.