Nokea
A nurse in a psychiatric unit is planning care for a client who has paranoid personality disorder. Which of the following interventions should the nurse include?
- A. Encourage group therapy participation
- B. Avoid challenging the client’s paranoid beliefs
- C. Maintain eye contact during conversations
- D. Use humor to reduce the client’s anxiety
Correct Answer: B
Rationale: The correct answer is B: Avoid challenging the client’s paranoid beliefs. This is essential because challenging the client's beliefs can lead to increased defensiveness and mistrust. Instead, the nurse should validate the client's feelings without reinforcing the delusions. Encouraging group therapy (choice A) may exacerbate paranoia by increasing feelings of being scrutinized. Maintaining eye contact (choice C) may be perceived as threatening. Using humor (choice D) could be misinterpreted and lead to further distrust.
You may also like to solve these questions
A nurse is developing a plan of care for a client who has borderline personality disorder and exhibits manipulative behavior. Which of the following interventions should the nurse include?
- A. Encourage flexibility with unit rules
- B. Implement consistent limit-setting
- C. Allow the client to negotiate consequences
- D. Avoid addressing manipulative behavior
Correct Answer: B
Rationale: The correct answer is B: Implement consistent limit-setting. For clients with borderline personality disorder and manipulative behavior, consistent limit-setting helps establish boundaries and promote a sense of security. By enforcing clear and consistent rules, the nurse can prevent manipulation and maintain a therapeutic environment. Encouraging flexibility with unit rules (choice A) may enable manipulation and disrupt the treatment process. Allowing the client to negotiate consequences (choice C) can reinforce manipulative behaviors. Avoiding addressing manipulative behavior (choice D) can lead to escalation and reinforcement of maladaptive behaviors.
A nurse is counseling an adult client whose parent just died. The client states, 'My son is 4, and I don’t know how he’ll react when he finds out that grandpa died.' The nurse should inform the client that the preschool-age child commonly has which of the following concepts of death?
- A. Death is not permanent and the loved one may come back to life
- B. Death is contagious and can cause other people he loves to die
- C. Death creates an interest in the physical aspects of dying
- D. Death is a part of life that eventually happens to everyone
Correct Answer: A
Rationale: The correct answer is A: Death is not permanent and the loved one may come back to life. Preschool-age children often have an understanding of death as temporary, believing that the deceased may come back to life. This is due to their cognitive development and limited understanding of the finality of death. Other choices are incorrect: B is incorrect as children do not typically view death as contagious; C is incorrect as preschoolers often lack a detailed interest in the physical aspects of dying; D is incorrect as preschoolers may not fully grasp the concept of death being a natural part of life.
A nurse is caring for a client who has major depressive disorder and is prescribed sertraline. Which of the following instructions should the nurse provide?
- A. Take the medication at bedtime
- B. Expect results within 1 to 2 days
- C. Avoid consuming grapefruit juice
- D. Stop taking the medication once symptoms improve
Correct Answer: C
Rationale: The correct answer is C: Avoid consuming grapefruit juice. Grapefruit juice can interact with sertraline, leading to increased levels of the medication in the bloodstream, potentially causing side effects or toxicity. It is essential for the nurse to instruct the client to avoid grapefruit juice to ensure the safe and effective use of sertraline. Taking the medication at bedtime (choice A) is not specifically necessary for sertraline. Expecting results within 1 to 2 days (choice B) is incorrect as antidepressants like sertraline typically take weeks to show full effects. Stopping the medication once symptoms improve (choice D) can be dangerous as abruptly discontinuing an antidepressant can lead to withdrawal symptoms or a relapse of depression.
A nurse is reviewing laboratory values for a client who has bipolar disorder and a prescription for lithium. Which of the following laboratory results places the client at risk for lithium toxicity?
- A. Calcium 9.0 mg/dL
- B. Sodium 130 mEq/L
- C. Chloride 98 mEq/L
- D. Potassium 5.0 mEq/L
Correct Answer: B
Rationale: The correct answer is B: Sodium 130 mEq/L. Low sodium levels increase the risk of lithium toxicity as lithium competes with sodium for reabsorption in the kidneys. This can lead to higher lithium levels in the bloodstream, putting the client at risk for toxicity. The other choices (A, C, D) are within normal ranges and do not directly impact lithium toxicity. Therefore, the client with low sodium levels is at the highest risk for lithium toxicity.
A nurse is providing teaching to the daughter of an older client who has obsessive-compulsive disorder. Which of the following statements by the daughter indicates an understanding of the disorder?
- A. I will limit my mother’s clothing choices when she is getting dressed
- B. I will provide my mother with detailed instructions about how to perform self-care
- C. I will wake my mother up a couple of times in the night to check on her
- D. I will discourage my mother from talking about physical complaints
Correct Answer: B
Rationale: The correct answer is B: "I will provide my mother with detailed instructions about how to perform self-care." This statement indicates an understanding of obsessive-compulsive disorder (OCD) because individuals with OCD often struggle with performing daily tasks due to their obsessive thoughts and compulsive behaviors. By providing detailed instructions, the daughter is acknowledging the need for structured routines to help her mother manage her symptoms.
A: Limiting clothing choices does not address the underlying issues of OCD and may exacerbate anxiety.
C: Waking the mother up to check on her reinforces compulsions, which is counterproductive in treating OCD.
D: Discouraging the mother from talking about physical complaints does not address the core symptoms of OCD.
By choosing option B, the daughter shows insight into the importance of providing support and guidance in managing the challenges associated with OCD.