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The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states, "I don't need to be here," and tells the RN that she believes that the TV talks to her. The RN should document these assessment statements in which section of the mental status exam?
- A. Insight and judgment.
- B. Mood and affect.
- C. Remote memory.
- D. Level of concentration.
Correct Answer: A
Rationale: The client's statement of not needing to be hospitalized and her belief that the TV talks to her indicate impaired insight and judgment. Insight and judgment evaluate the client's awareness of their condition and ability to make sound decisions. Mood and affect assess emotional state, remote memory evaluates recall of past events, and level of concentration assesses attention and focus, none of which directly address the client's lack of insight and judgment in this scenario.
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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.
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.
What intervention is best for the nurse to implement for a male client with schizophrenia who is demonstrating echolalia, which is becoming annoying to other clients on the unit?
- A. Avoid recognizing the behavior.
- B. Isolate the client from other clients.
- C. Administer a PRN sedative.
- D. Escort the client to his room.
Correct Answer: D
Rationale: Echolalia, the constant repetition of what others are saying, can be disruptive to the therapeutic environment. The most appropriate intervention is to escort the client to his room. This action provides the client with a private space where he can engage in the behavior without disturbing other clients. Avoiding recognition of the behavior (Choice A) may not address the issue and could lead to increased annoyance among other clients. Isolating the client (Choice B) may have negative psychological effects and should be avoided unless absolutely necessary for safety concerns. Administering a PRN sedative (Choice C) should be considered only as a last resort and if other de-escalation techniques have been unsuccessful.
A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN?
- A. Is attempting the physically restrain the patient.
- B. Remains at a distance of 4 feet from the client.
- C. Tells the client to go to the quiet area of the unit.
- D. Is using a loud voice to talk to the client.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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.