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A nurse is planning care for a client who has borderline personality disorder and engages in self-mutilation. Which intervention should the nurse include?
- A. Restrict the client's access to personal belongings.
- B. Encourage the client to express feelings of anger.
- C. Place the client in seclusion when self-injurious behavior occurs.
- D. Tell the client to stop the self-mutilation behavior.
Correct Answer: B
Rationale: The correct answer is B: Encourage the client to express feelings of anger. This intervention helps the client explore and process underlying emotions contributing to self-mutilation. It promotes emotional awareness and healthy coping mechanisms. Restricting personal belongings (A) may escalate feelings of frustration. Seclusion (C) can be traumatic and worsen abandonment fears. Telling the client to stop (D) oversimplifies a complex issue and may lead to resistance.
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A nurse is caring for a client who has a history of opioid use disorder. Which medication should the nurse anticipate administering to prevent withdrawal symptoms?
- A. Methadone
- B. Disulfiram
- C. Naloxone
- D. Bupropion
Correct Answer: A
Rationale: Rationale: A nurse should anticipate administering Methadone to prevent withdrawal symptoms in a client with opioid use disorder. Methadone is a long-acting opioid agonist that helps manage withdrawal symptoms and cravings, making it an effective treatment option. Disulfiram is used for alcohol dependence, Naloxone is an opioid antagonist used for overdose reversal, and Bupropion is an antidepressant. These medications are not indicated for preventing opioid withdrawal symptoms.
A nurse is planning care for a client who has borderline personality disorder and engages in self-mutilation. Which intervention should the nurse include?
- A. Restrict the client's access to personal belongings.
- B. Encourage the client to express feelings of anger.
- C. Place the client in seclusion when self-injurious behavior occurs.
- D. Tell the client to stop the self-mutilation behavior.
Correct Answer: B
Rationale: The correct answer is B: Encourage the client to express feelings of anger. For a client with borderline personality disorder and self-mutilation behavior, it is essential to address underlying emotions. Encouraging the client to express feelings of anger can help them identify and process their emotions, reducing the likelihood of resorting to self-injury. Restricting access to personal belongings (A) may lead to feelings of frustration and exacerbate the behavior. Placing the client in seclusion (C) may cause feelings of abandonment and increase distress. Simply telling the client to stop self-mutilation (D) overlooks the complex emotional reasons behind the behavior.
A nurse is caring for a client with major depressive disorder who has a new prescription for fluoxetine. Which statement by the client indicates an understanding of the medication?
- A. I should expect to see improvement in my mood within a few days.
- B. I may experience increased thoughts of suicide at the beginning of treatment.
- C. I need to avoid foods high in tyramine while taking this medication.
- D. I will need to have my lithium levels checked regularly.
Correct Answer: B
Rationale: The correct answer is B: "I may experience increased thoughts of suicide at the beginning of treatment." This statement indicates an understanding of the medication because fluoxetine, an SSRI, can initially increase suicidal ideation in clients with major depressive disorder due to sudden improvement in energy levels before mood improvement. This is important for the client to know for safety monitoring.
Choice A is incorrect as improvement in mood may take several weeks, not days. Choice C is incorrect as avoiding tyramine-rich foods is relevant for MAOIs, not SSRIs like fluoxetine. Choice D is incorrect as lithium levels are monitored for clients taking lithium, not fluoxetine.
A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan?
- A. Place the client in seclusion when he exhibits signs of anxiety.
- B. Encourage the client to spend time in the dayroom.
- C. Withdraw the client's TV privileges if he does not attend group therapy.
- D. Encourage the client to take frequent rest periods.
Correct Answer: D
Rationale: The correct answer is D: Encourage the client to take frequent rest periods. During manic episodes in bipolar disorder, individuals often experience decreased need for sleep and increased energy levels. Encouraging the client to take rest periods can help prevent exhaustion and promote relaxation, which may help in managing manic symptoms. Placing the client in seclusion when anxious (choice A) can exacerbate feelings of isolation and distress. Encouraging the client to spend time in the dayroom (choice B) may increase stimulation, which can worsen manic symptoms. Withdrawing TV privileges (choice C) for not attending group therapy may not directly address the manic symptoms. Thus, choice D is the most appropriate intervention for managing mania in this client.
A nurse in an acute care mental health facility is placing a client in seclusion and restraints. Which of the following actions should the nurse plan to take?
- A. Ensure that the prescription for restraints be renewed every 6 hr.
- B. Document the client's behavior every 15 min.
- C. Request a provider to evaluate the client in person every 36 hr.
- D. Plan to monitor the client every 30 min while restrained.
Correct Answer: B
Rationale: The correct answer is B: Document the client's behavior every 15 min. This action is crucial in ensuring the safety and well-being of the client in seclusion and restraints. Documenting the client's behavior every 15 minutes allows the nurse to monitor for any changes in the client's condition, response to the intervention, or signs of distress. It helps in identifying any potential risks or improvements, enabling timely intervention or adjustment of the care plan. This frequent documentation also ensures compliance with regulatory standards and serves as a detailed record of the client's status during the intervention.
Other choices are incorrect:
A: Ensuring prescription renewal every 6 hours may be too frequent and not necessary unless there are specific indications.
C: Requesting a provider evaluation every 36 hours may not provide timely assessment and intervention in case of any changes in the client's condition.
D: Monitoring the client every 30 minutes while restrained may not be frequent enough to detect sudden changes or risks promptly.