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A nurse is admitting a client who is exhibiting manic behavior. The client reports recent personal stressors including the loss of her mother and a divorce. Which of the following is the priority nursing action?
- A. Identifying support systems.
- B. Assisting the client in identifying coping behaviors.
- C. Encouraging self-care.
- D. Preventing self-directed violence.
Correct Answer: D
Rationale: Safety is the priority for clients experiencing manic episodes, as they are at risk for self-harm.
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A nurse is assessing a parent who lost a 12-year-old child in a car crash 2 years ago. Which of the following findings indicates the client is exhibiting manifestations of prolonged grieving?
- A. Leaves the child's room exactly as it was before the loss
- B. Volunteers at a local children's hospital
- C. Talks about the child in the past tense
- D. Visits the child's grave every week after worship services
Correct Answer: A
Rationale: In prolonged grief, individuals may struggle to move forward and avoid changing their environment.
A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client’s head is down, and he is wringing his hands. Which of the following actions should the nurse take?
- A. Encourage the client to go back to bed.
- B. Give the client a PRN sleeping medication.
- C. Remain with the client.
- D. Explore alternatives to pacing the floor with the client.
Correct Answer: C
Rationale: The correct answer is C: Remain with the client. By remaining with the client, the nurse can provide support and reassurance, assess the client's emotional state, and ensure the client's safety. This action shows empathy and promotes therapeutic communication. Encouraging the client to go back to bed (A) may not address the underlying issue causing the restlessness. Giving a PRN sleeping medication (B) without further assessment may not be appropriate and could mask the client's feelings. Exploring alternatives to pacing (D) is a good intervention but should come after providing immediate support and understanding the client's needs.
A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?
- A. Identify the client's nutritional status.
- B. Request a mental health consult.
- C. Plan a therapeutic diet for the client.
- D. Provide a structured environment for the client.
Correct Answer: A
Rationale: The correct answer is A: Identify the client's nutritional status. The priority is to assess the client's nutritional status due to the significant weight loss. This will help determine if the client is at risk of malnutrition or other health issues. B, requesting a mental health consult, is not the first priority as addressing the client's physical health is crucial before addressing mental health concerns. Planning a therapeutic diet (C) can come after assessing the nutritional status. Providing a structured environment (D) may be important but not as critical as determining the client's nutritional status first.
A nurse is caring for a postpartum client who tells the nurse that she does not want any more children. The client asks which birth control method the nurse would recommend. Which of the following responses should the nurse make?
- A. "It's your choice, of course, but birth control pills are the most reliable."
- B. "I'd consider an intrauterine device. You won't have to worry about pregnancy."
- C. "Your provider usually recommends a diaphragm and spermicidal cream."
- D. "Let's talk about the available options and go from there."
Correct Answer: D
Rationale: The correct answer is D because it promotes patient-centered care by involving the client in decision-making. The nurse should discuss available birth control options with the client to ensure the method aligns with her preferences, lifestyle, and medical history. This approach empowers the client to make an informed decision that best suits her needs.
Option A is incorrect because it assumes the client's preference without exploring other options. Option B may not align with the client's preferences, and the nurse should not impose a specific method. Option C assumes the provider's recommendation without considering the client's preferences. These options do not prioritize shared decision-making and individualized care.
A nurse is preparing to teach a client about his prescription of lithium for the treatment of bipolar disorder. Which of the following statements should the nurse include in the teaching?
- A. "You will need to consume a low-salt diet while on this medication."
- B. "You will need your blood levels drawn weekly during the first month."
- C. "You will need to take this medication on an empty stomach."
- D. "You will need to stop this medication if you experience diarrhea."
Correct Answer: B
Rationale: Lithium levels need frequent monitoring at the start of therapy to prevent toxicity.