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A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. He was divorced one year ago, lost his job four months ago, and suffered a breakup of his current relationship last week. What is the most likely source of this client's current feelings of depression?
- A. Feelings of frustration.
- B. A sense of loss.
- C. Poor self-esteem.
- D. A lack of intimate relationships.
Correct Answer: B
Rationale: The client's recent history of divorce, job loss, and breakup of a current relationship indicates a series of significant losses. These losses are likely the primary source of his feelings of depression, leading to a sense of loss. While feelings of frustration (choice A) and poor self-esteem (choice C) could be contributing factors, the immediate trigger for his current emotional state appears to be the series of losses. A lack of intimate relationships (choice D) may be a consequence of the client's depressive symptoms rather than the root cause in this scenario.
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A client with a diagnosis of schizophrenia is exhibiting negative symptoms such as anhedonia and social withdrawal. Which intervention should be a priority for the nurse?
- A. Encourage participation in group activities.
- B. Administer prescribed antipsychotic medication.
- C. Assist the client in setting realistic goals.
- D. Promote engagement in social interactions.
Correct Answer: A
Rationale: Encouraging participation in group activities is a priority intervention for a client with schizophrenia exhibiting negative symptoms like anhedonia and social withdrawal. Group activities provide structured social interactions and can help the client gradually re-engage with others, potentially reducing social withdrawal and improving social skills. Administering antipsychotic medication (Choice B) is essential in managing positive symptoms of schizophrenia such as hallucinations and delusions, not negative symptoms like anhedonia and social withdrawal. While assisting the client in setting realistic goals (Choice C) is important for overall care, addressing social withdrawal and anhedonia is more immediate. Promoting engagement in social interactions (Choice D) is beneficial, but encouraging participation in group activities provides a structured and supportive environment that can specifically target the negative symptoms being exhibited.
A client with depression remains in bed most of the day, declines activities, and refuses meals. Which nursing problem has the greatest priority for this client?
- A. Loss of interest in diversional activities.
- B. Social isolation.
- C. Refusal to address nutritional needs.
- D. Low self-esteem.
Correct Answer: C
Rationale: The correct answer is C: 'Refusal to address nutritional needs.' In this scenario, the client's refusal to eat and address their nutritional needs poses an immediate threat to their physical health. Without proper nutrition, the client is at risk of malnutrition and its associated complications. While addressing social isolation, low self-esteem, and loss of interest in diversional activities are important aspects of holistic care for a client with depression, ensuring proper nutrition takes precedence due to the critical impact it has on the client's physical well-being. Therefore, the priority is to address the client's refusal to eat and address their nutritional needs to prevent further deterioration of their health.
When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic, the client tells the nurse that he usually takes a different dosage. What action should the nurse take?
- A. Tell him to take the medication then verify the dosage at the next healthcare team meeting.
- B. Withhold the medication until the dosage can be confirmed.
- C. Inform him that he may refuse the medication and document whether or not he takes it.
- D. Explain to the client that the dosage has been changed.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client diagnosed with obsessive-compulsive disorder (OCD) engages in repetitive hand washing that lasts for several hours. Which strategy should the nurse use to manage this behavior?
- A. Encourage the client to continue the behavior to alleviate anxiety.
- B. Establish a routine schedule for hand washing.
- C. Gradually reduce the amount of time spent on the behavior.
- D. Ignore the behavior as much as possible.
Correct Answer: C
Rationale: In managing obsessive-compulsive disorder (OCD), it's crucial to gradually reduce the compulsive behavior to help the client learn to manage anxiety in a structured manner. Encouraging the client to continue the behavior (Choice A) would reinforce the cycle of compulsions. While establishing a routine schedule (Choice B) may provide some structure, it doesn't address the core issue of excessive hand washing. Ignoring the behavior (Choice D) may lead to worsening symptoms and does not help the client in managing their OCD effectively.
Which therapeutic communication statement might a psychiatric-mental health registered nurse use when a patient's nursing diagnosis is altered thought processes?
- A. I know you say you hear voices, but I cannot hear them.
- B. Stop listening to the voices, they are NOT real.
- C. You say you hear voices, what are they telling you?
- D. Please tell the voices to leave you alone for now.
Correct Answer: C
Rationale: Choice C is the correct answer because it acknowledges the patient's experience of hearing voices, showing empathy and exploring the content of the hallucinations. This type of therapeutic communication encourages the patient to express their thoughts and feelings without judgment. Choices A, B, and D are incorrect because they either deny the patient's experience, dismiss the hallucinations as not real, or suggest eliminating them, which can be perceived as invalidating the patient's feelings and experiences.