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A female client on a psychiatric unit is sweating profusely while vigorously doing push-ups and then running the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to verbally attack other clients. What intervention is most appropriate for the RN to use to manage the client's behavior?
- A. Assist the client to a safe area to avoid injury.
- B. Establish clear and firm limits with the client.
- C. Offer medication to help calm the client down.
- D. Speak with the client in a calm, non-threatening manner.
Correct Answer: A
Rationale: Assisting the client to a safe area is the most appropriate intervention in this scenario. This action helps prevent injury to the client and others while allowing for de-escalation in a controlled environment. While establishing clear and firm limits (Choice B) may be necessary in some situations, the immediate priority here is safety. Offering medication (Choice C) should not be the first response unless the situation escalates further and poses a risk to the client or others. Speaking with the client in a calm, non-threatening manner (Choice D) may not be effective when the client is in an agitated state and engaging in risky behavior.
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A client with alcohol use disorder is being treated in a rehabilitation facility. Which behavior indicates that the client is making progress in recovery?
- A. Attends all scheduled therapy sessions regularly.
- B. Is participating in group therapy and sharing experiences.
- C. Completes a work-study program.
- D. Has a decreased need for psychiatric medication.
Correct Answer: B
Rationale: The correct answer is B. Participation in group therapy and sharing experiences is a positive sign of progress in recovery for a client with alcohol use disorder. It fosters peer support, allows for personal insight, and encourages social interaction, which are essential aspects of the recovery process. Choice A, attending all scheduled therapy sessions regularly, is important but may not necessarily indicate the same level of progress as active participation in group therapy. Choice C, completing a work-study program, is not directly related to the client's recovery from alcohol use disorder. Choice D, having a decreased need for psychiatric medication, is not necessarily a reliable indicator of progress in recovery from alcohol use disorder, as medication management is a separate aspect of treatment.
A client with major depressive disorder is prescribed lithium carbonate. Which finding should the RN report to the healthcare provider?
- A. Serum lithium level of 0.8 mEq/L
- B. Blood urea nitrogen (BUN) level of 16 mg/dL
- C. Serum sodium level of 138 mEq/L
- D. Urine output of 800 mL in 24 hours
Correct Answer: B
Rationale: The correct answer is B. Elevated BUN levels may indicate renal impairment, which is crucial to report for clients on lithium due to its potential kidney effects. Option A, a serum lithium level of 0.8 mEq/L, is within the therapeutic range for lithium and does not require immediate reporting. Option C, a serum sodium level of 138 mEq/L, is within the normal range and not directly related to lithium therapy. Option D, urine output of 800 mL in 24 hours, may indicate a need for further assessment but is not the most critical finding to report compared to potential renal impairment indicated by an elevated BUN level.
The nurse is assessing a client who has schizophrenia and is exhibiting symptoms of paranoia. Which behavior would the nurse most likely observe?
- A. The client is seen as unmotivated and withdrawn.
- B. The client is preoccupied with a fear of being harmed.
- C. The client displays a blunted affect and lacks emotional response.
- D. The client avoids group activities and shows decreased appetite.
Correct Answer: B
Rationale: In clients with paranoia, they typically exhibit an intense fear of being harmed, persecuted, or targeted by others. This fear often dominates their thoughts and can significantly impact their daily functioning and interactions. Choice A, being unmotivated and withdrawn, is more indicative of negative symptoms of schizophrenia, such as avolition and social withdrawal. Choice C, displaying a blunted affect and lacking emotional response, is associated with flat affect, a symptom commonly seen in schizophrenia but not specific to paranoia. Choice D, avoiding group activities and showing decreased appetite, may be related to various symptoms or side effects, but it is not a defining characteristic of paranoia in schizophrenia.
A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms?
- A. Diphenhydramine (Benadryl)
- B. Perphenazine (Trilafon)
- C. Isocarboxazid (Marplan)
- D. Chlordiazepoxide (Librium)
Correct Answer: D
Rationale: Chlordiazepoxide (Librium) is the correct choice for managing benzodiazepine withdrawal symptoms. Benzodiazepines are commonly used drugs that can lead to physical dependence, and abrupt discontinuation can result in withdrawal symptoms. Chlordiazepoxide, a benzodiazepine itself, is often used in a controlled manner to taper off the drug gradually and manage withdrawal symptoms effectively. Choice A, Diphenhydramine, is an antihistamine and not typically used to manage benzodiazepine withdrawal. Choice B, Perphenazine, is an antipsychotic medication used to treat psychotic disorders, not specifically benzodiazepine withdrawal symptoms. Choice C, Isocarboxazid, is a monoamine oxidase inhibitor (MAOI) used in the treatment of depression and not indicated for benzodiazepine withdrawal.
A client in the emergency department presents with confusion, disorientation, and agitation after drinking alcohol. Which diagnostic test should the nurse anticipate to assess for potential complications?
- A. Complete blood count (CBC)
- B. Electrolyte panel
- C. Liver function tests
- D. Urinalysis
Correct Answer: B
Rationale: The correct answer is an electrolyte panel. When a client presents with confusion, disorientation, and agitation after drinking alcohol, it indicates potential complications such as electrolyte imbalances. Monitoring electrolyte levels is crucial in these cases to detect and address abnormalities that may result from alcohol intake. While a complete blood count (choice A) may provide some valuable information, it is not the primary test to assess for alcohol-related complications presenting with these symptoms. Liver function tests (choice C) are more specific for assessing liver damage due to chronic alcohol use rather than immediate complications. Urinalysis (choice D) may help detect some issues but is not the most appropriate initial test to assess for potential complications in this scenario.