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A nurse is caring for an adolescent client who begins to cry and states, 'Nobody loves me. I don't deserve to be here!' Which of the following responses should the nurse make?
- A. Why do you think nobody loves you?
- B. I am sure your parents love you
- C. Don't worry, things will get better.'
- D. Let's talk about what is upsetting you.'
Correct Answer: D
Rationale: The correct response is D: "Let's talk about what is upsetting you." This response is appropriate as it shows empathy, encourages communication, and allows the client to express their feelings. It opens up a dialogue for the nurse to understand the root cause of the client's distress and provide appropriate support.
Rationale:
1. Empathy: By acknowledging the client's emotions and offering to talk, the nurse shows empathy and support.
2. Communication: Encouraging the client to express their feelings promotes communication and helps the nurse understand the client's perspective.
3. Assessment: Talking about what is upsetting the client allows the nurse to assess the situation and provide appropriate interventions.
Summary of other choices:
A: Why do you think nobody loves you? - This response may come off as dismissive or invalidating the client's feelings.
B: I am sure your parents love you - This response assumes the client's parents love them without addressing the client's current distress.
C: Don't worry,
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After taking fluphenazine for several days, a client states to the nurse, 'For some reason I can't sit still restless all the time.' The nursing assessment of this client is likely to indicate which of the following?
- A. Tardive dyskinesia
- B. Pseudoparkinsonism
- C. Akathisia
- D. Acute dystonia
Correct Answer: C
Rationale: The correct answer is C: Akathisia. Akathisia is a common extrapyramidal side effect of antipsychotic medications like fluphenazine, causing an inner restlessness and inability to sit still. This is characterized by a compelling need to move and can be distressing for the client. Tardive dyskinesia (A) is a late-occurring side effect characterized by involuntary repetitive movements, not restlessness. Pseudoparkinsonism (B) presents with symptoms similar to Parkinson's disease such as tremors and rigidity. Acute dystonia (D) is a sudden onset of muscle spasms and abnormal postures, not restlessness.
Client's behavior continues to escalate. A nurse is caring for a client in an inpatient psychiatry unit, Drag words from the choices below to fill in each blank in the following sentence ,Which of the following actions should the nurse take first? The nurse should ___ followed by ___.
- A. Place the client in restraints
- B. Grab the client's hand
- C. Offer the client a physical outlet
- D. Offer the client medication
Correct Answer: C,D
Rationale: Action to Take: Offer the client a physical outlet, Offer the client medication; Potential Condition: Escalating behavior; Parameter to Monitor: Client's behavior, Client's response to offered outlets.
Rationale: When a client's behavior continues to escalate in an inpatient psychiatry unit, the nurse's first action should be to offer the client a physical outlet as a non-restrictive and non-confrontational approach to de-escalate the situation. This allows the client to release built-up tension and energy in a safe manner. Additionally, offering medication can help address any underlying anxiety or agitation contributing to the escalation. By monitoring the client's behavior and response to the offered outlets, the nurse can assess the effectiveness of the interventions and make further adjustments as needed. Placing the client in restraints should be avoided as it can escalate the situation further, and grabbing the client's hand may be perceived as confrontational or threatening, potentially worsening the behavior.
The client exhibits a flat affect, psychomotor retardation, and a depressed mood. The nurse attempts to engage the client in an interaction, but the client does not respond to the nurse. Which response by the nurse is most therapeutic?
- A. I will sit here with you for 10 minutes.
- B. I will find someone else for you to talk with.
- C. I will come back a little bit later
- D. I will get you something to read
Correct Answer: A
Rationale: The correct answer is A: "I will sit here with you for 10 minutes." This response is most therapeutic because it demonstrates the nurse's willingness to provide support and presence to the client, which can help establish a sense of safety and trust. Sitting with the client also allows for non-verbal communication and gives the client an opportunity to feel heard and understood. It shows empathy and a non-judgmental attitude, which are essential in building a therapeutic relationship.
Choice B is incorrect as it dismisses the client's need for interaction. Choice C is less effective because it postpones the interaction and may convey a lack of immediate support. Choice D distracts the client and does not address the client's emotional state. Overall, choice A is the most appropriate response for establishing a therapeutic connection with the client in this scenario.
A nurse is caring for client who spent the past several minutes mumbling about being doomed to die and is now pacing in an increasingly agitated and angry manner. Which of the following actions is should the nurse take?
- A. Administer PRN medication for agitation
- B. Request a prescription for physical restraints
- C. Place the client in seclusion
- D. Attempt to reduce environmental stimuli
Correct Answer: D
Rationale: The correct answer is D: Attempt to reduce environmental stimuli. This is the appropriate action because the client is exhibiting signs of agitation and distress. By reducing environmental stimuli, such as noise and visual distractions, the nurse can help calm the client and prevent escalation of the situation. Administering medication, using physical restraints, or placing the client in seclusion should only be considered as a last resort when all other interventions have failed. These options can further agitate the client and compromise their autonomy. It is important for the nurse to prioritize non-pharmacological interventions and maintain a therapeutic environment to support the client's emotional well-being.
A nurse is preparing to administer furosemide 2 mg/kg/day IV bolus divided in equal doses every 8 hr to a toddler who weighs 22 lb. Available is furosemide injection 5 mg/mL. how many mL should the nurse administer per dose? (Round the answer to the nearest tenth.)
Correct Answer: 1.3
Rationale: To calculate the dose of furosemide, first convert the toddler's weight from lb to kg: 22 lb ÷ 2.2 = 10 kg. Then, calculate the total daily dose: 2 mg/kg/day x 10 kg = 20 mg/day. Since the dose is divided into equal doses every 8 hours, divide the total daily dose by 3 (24 hours ÷ 8 hours) to get the dose per administration: 20 mg/day ÷ 3 = 6.67 mg/dose. To convert this to mL, divide by the concentration of the injection: 6.67 mg ÷ 5 mg/mL = 1.334 mL, rounded to 1.3 mL. Therefore, the correct answer is 1.3 mL per dose.
Summary of Incorrect Choices:
- A, B, C, D, E, F, G: These choices did not correctly calculate the dose based on the toddler's