Nokea
A nurse is reviewing the medical records for clients. Which of the following findings should the nurse identify as a risk factor for violent behavior?
- A. Schizoid personality disorder
- B. Alcohol intoxication
- C. Dysthymic disorder
- D. Long-term isolation
Correct Answer: B
Rationale: The correct answer is B: Alcohol intoxication. Alcohol intoxication can impair judgment, lower inhibitions, and increase aggression, leading to a higher risk of violent behavior. Schizoid personality disorder (A) is characterized by social detachment, not necessarily violence. Dysthymic disorder (C) involves chronic low mood but not a direct risk for violent behavior. Long-term isolation (D) may contribute to mental health issues but does not directly indicate violent behavior.
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A nursing is advising an assistive personnel (AP) on the care of a client who has major depressive disorder. The AP states that he is irritated by the client’s depression. Which of the following statements by the nurse is appropriate?
- A. Please don’t take what the client said seriously when she is depressed
- B. It’s important that the client feel safe verbalizing how she is feeling
- C. Everybody feels that way about this client so don’t worry about it
- D. I’ll change your assignment to someone who doesn’t have depressive disorder
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Changing the AP's assignment is appropriate because it addresses the issue of the AP's irritation towards the client's depression. It ensures the client's care is not compromised and maintains a supportive environment. This action also prevents negative attitudes from affecting the client's well-being.
Summary of other choices:
A: Incorrect. Minimizing the client's feelings is inappropriate and may invalidate their experiences.
B: Incorrect. While it is important for the client to verbalize feelings, the focus here is on addressing the AP's behavior.
C: Incorrect. Dismissing the AP's feelings and normalizing negative attitudes are not appropriate responses.
E, F, G: Not provided, but based on the context, they are likely to be irrelevant or inappropriate responses.
A nurse in an alcohol treatment facility is caring for a client who states 'my job is so stressful that the only way I can cope is to drink.' The nurse should recognize that the client is displaying which of the following defense mechanisms?
- A. Repression
- B. Rationalization
- C. Introjection
- D. Intellectualization
Correct Answer: B
Rationale: The correct answer is B: Rationalization. Rationalization is a defense mechanism where individuals justify their behaviors or feelings with logical reasoning or excuses. In this case, the client is justifying their drinking by attributing it to the stress of their job. This defense mechanism helps the individual avoid facing the real underlying issues causing their behavior.
Choice A: Repression involves pushing unwanted thoughts or feelings into the unconscious mind, which is not demonstrated by the client's statement.
Choice C: Introjection is the internalization of external beliefs or values, not applicable in this context.
Choice D: Intellectualization is the process of focusing on facts and logic to avoid dealing with emotions, which is not evident in the client's statement.
A nurse is preparing to administer chlorpromazine hydrochloride 25 mg PO to an older adult client. Available is chlorpromazine hydrochloride syrup 10 mg/5 mL. How many mL should the nurse administer?
- A. 12.5
- B. 10
- C. 15
- D. 5
Correct Answer: A
Rationale: The correct answer is A: 12.5 mL. To calculate this, we first determine the total amount needed, which is 25 mg. Then, we use the concentration of the syrup, which is 10 mg/5 mL. By setting up a proportion (25 mg = x mL), we can cross multiply to find x, which equals 12.5 mL. Choice B (10 mL) is incorrect because it does not provide the full 25 mg dose. Choices C (15 mL) and D (5 mL) are incorrect as they do not align with the calculated dose based on the concentration of the syrup.
A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer’s disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include?
- A. Position the mattress on the floor
- B. Install sensor devices on outside doors
- C. Encourage physical activity prior to bedtime
- D. Put locks at top of doors
Correct Answer: A
Rationale: The correct answer is A: Position the mattress on the floor. Placing the mattress on the floor reduces the risk of injury if the client falls out of bed while wandering at night. This option prioritizes safety by minimizing the distance of potential falls. Installing sensor devices on outside doors (B) may alert the caregiver but does not directly address the risk of falls. Encouraging physical activity prior to bedtime (C) could increase agitation and wandering behavior. Putting locks at the top of doors (D) could pose a safety risk if emergency access is needed.
A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and is taking haloperidol. Which of the following clinical findings is the nurse’s priority?
- A. High fever
- B. Insomnia
- C. Urinary hesitancy
- D. Headache
Correct Answer: A
Rationale: The correct answer is A: High fever. The priority finding is high fever because it could indicate a potentially serious adverse reaction called neuroleptic malignant syndrome (NMS) associated with haloperidol use. NMS is a life-threatening condition characterized by fever, altered mental status, muscle rigidity, and autonomic dysfunction. Prompt recognition and treatment of NMS are crucial to prevent complications. Insomnia (B), urinary hesitancy (C), and headache (D) are common side effects of haloperidol but are not as urgent as high fever, which could signify a medical emergency.