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A nurse is caring for a client who has depression following a recent job loss. Which of the following questions should the nurse ask to assess the client’s personal coping skills?
- A. How does this situation affect your life?
- B. Do you see your current situation affecting your future?
- C. Can you describe how you are currently feeling?
- D. How have you dealt with similar situations in the past?
Correct Answer: D
Rationale: The correct answer is D: How have you dealt with similar situations in the past? This question assesses the client's personal coping skills by exploring their past strategies for managing challenging situations. By understanding their previous coping mechanisms, the nurse can identify effective approaches to support the client in managing their current depression.
A: How does this situation affect your life? - This question focuses on the impact of the current situation but does not directly assess the client's coping skills.
B: Do you see your current situation affecting your future? - This question explores the client's perspective on the influence of the situation on their future, but it does not specifically address coping skills.
C: Can you describe how you are currently feeling? - This question evaluates the client's emotional state but does not directly assess coping skills.
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A nurse is providing teaching to a client who has obsessive-compulsive disorder and engages in excessive handwashing. Which of the following instructions should the nurse include?
- A. Encourage the client to stop washing hands
- B. Allow additional time for rituals
- C. Limit ritual behaviors immediately
- D. Ignore the compulsions
Correct Answer: B
Rationale: The correct answer is B: Allow additional time for rituals. This is because abruptly stopping the handwashing rituals can lead to increased anxiety and distress for the client. Allowing additional time for rituals can help the client feel more in control and gradually work towards reducing the behavior. Encouraging the client to stop washing hands (A) abruptly can be counterproductive. Limiting ritual behaviors immediately (C) can also increase anxiety. Ignoring the compulsions (D) may worsen the condition.
A nurse is caring for a client who is involuntarily admitted for major depressive disorder and refuses to take prescribed antianxiety medication. Which of the following actions should the nurse take?
- A. Inform the client that he does not have the right to refuse medication
- B. Administer the medication to the client via IM injection
- C. Offer the client the medication at the next scheduled dose time
- D. Implement consequences until the client takes the medication
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Implementing consequences until the client takes the medication is the most appropriate action as the client is involuntarily admitted. This approach ensures the client's safety and well-being by addressing the refusal to take prescribed medication. Administering medication via IM injection (B) may escalate the situation and violate the client's rights. Informing the client that he does not have the right to refuse medication (A) is inaccurate and may lead to resistance. Offering the medication at the next scheduled dose time (C) does not address the client's refusal.
A nurse is planning care for a client who has bipolar disorder. The client reports not sleeping for 3 days and is exhibiting a euphoric mood. The nurse should identify which of the following as the priority intervention.
- A. Secure the client’s valuable possessions
- B. Limit loud noises in the client’s environment
- C. Encourage the client to participate in structured solitary activities
- D. Provide high calorie snacks to the client
Correct Answer: D
Rationale: The correct answer is D: Provide high calorie snacks to the client. The priority intervention in this scenario is to address the client's lack of sleep and increased energy levels due to mania. Providing high-calorie snacks can help stabilize blood sugar levels and provide sustained energy, potentially aiding in promoting sleep. The other choices are incorrect because securing valuable possessions, limiting loud noises, and encouraging solitary activities do not directly address the immediate need to manage the client's symptoms related to lack of sleep and euphoria.
A nurse is caring for a client who has a new diagnosis of bulimia nervosa. Which of the following diagnosis procedures should the nurse anticipate the provider should describe during the medical evaluation?
- A. Chest x-ray
- B. ECG
- C. Coagulation studies
- D. Liver function test
Correct Answer: B
Rationale: The correct answer is B: ECG. A provider may order an ECG during the medical evaluation of a client with bulimia nervosa to assess for any potential cardiac complications, such as electrolyte imbalances or arrhythmias due to purging behaviors. This test helps in evaluating the overall cardiac health of the client. Chest x-ray (A) is not typically indicated in the evaluation of bulimia nervosa unless there are specific respiratory symptoms. Coagulation studies (C) are not directly related to the diagnosis of bulimia nervosa. Liver function test (D) is not a common diagnostic procedure for bulimia nervosa unless there are specific concerns about liver function due to other factors.
A nurse in a psychiatric facility is planning care for a client who has depression and is at risk for suicide. Which of the following interventions should the nurse implement?
- A. Assign the same staff to the client each shift
- B. Keep the client's room well-lit at all times
- C. Allow the client privacy at all times
- D. Provide access to sharp objects
Correct Answer: A
Rationale: The correct answer is A: Assign the same staff to the client each shift. Consistency in staff helps build trust and rapport, crucial for clients with depression and suicide risk. This continuity allows staff to better monitor the client's behavior, mood changes, and suicide risk factors. The familiarity also helps in identifying early warning signs and implementing appropriate interventions promptly.
Choice B is incorrect because while keeping the room well-lit may help prevent self-harm, it does not address the underlying need for consistent support and monitoring.
Choice C is incorrect as constant privacy may hinder the nurse's ability to assess the client's safety and intervene effectively.
Choice D is incorrect as providing access to sharp objects increases the client's risk of self-harm.