Nokea
A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage?
- A. He ingested the drug 3 hours prior to admission to the emergency center.
- B. The family reports that he took an entire bottle of acetaminophen (Tylenol).
- C. He is unresponsive to instructions and is unable to cooperate with emetic therapy.
- D. Those with repeated suicide attempts desire punishment to relieve their guilt.
Correct Answer: C
Rationale: The correct answer is C because the client's unresponsiveness to instructions and inability to cooperate with emetic therapy would make it challenging to implement such therapy effectively. In such cases, gastric lavage may be necessary to remove the ingested substance. Choices A and B are important considerations in treatment planning but do not directly indicate the need for gastric lavage. Choice D is incorrect as medical treatments should never be used as punitive measures but rather for therapeutic purposes.
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A client sought counseling after trying to rescue a neighbor involved in a house fire. Despite the client's efforts, the neighbor died. Which action does the nurse engage in with the client during the working phase of the nurse-client relationship?
- A. Exploring the client's ability to function
- B. Exploring the client's potential for self-harm
- C. Inquiring about the client's perception of appraisal of the neighbor's death
- D. Inquiring about and examining the client's feelings that may block adaptive coping
Correct Answer: D
Rationale: During the working phase of the nurse-client relationship, it is crucial for the nurse to inquire about and examine the client's feelings that may hinder adaptive coping. This helps the client process the traumatic event, explore their emotional responses, and identify any barriers to moving forward effectively. Exploring the client's ability to function (Choice A) may be more relevant in the assessment phase, while exploring the client's potential for self-harm (Choice B) is important but may not be the primary focus at this stage. Inquiring about the client's perception of the neighbor's death (Choice C) is valuable, but addressing feelings blocking adaptive coping is essential for therapeutic progress.
A nurse is caring for a client who is experiencing severe anxiety. Which intervention is most appropriate for the nurse to implement?
- A. Instruct the client to take deep breaths and focus on the present.
- B. Encourage the client to discuss their fears in detail.
- C. Distract the client with a humorous story or anecdote.
- D. Leave the client alone to process their emotions.
Correct Answer: A
Rationale: The correct intervention for a client experiencing severe anxiety is to instruct the client to take deep breaths and focus on the present. Deep breathing can help reduce the physiological symptoms of anxiety and provide the client with a way to regain control over their emotions. Choice B is incorrect as discussing fears in detail may escalate anxiety levels. Choice C is inappropriate as distracting the client may not address the root cause of anxiety. Choice D is not recommended as leaving the client alone can increase feelings of isolation and distress.
A female client with borderline personality disorder expresses fear of being abandoned by the nursing staff. What is the best nursing intervention?
- A. Reassure the client that she will not be abandoned.
- B. Set limits on the client's behavior and enforce them consistently.
- C. Encourage the client to talk about her fears.
- D. Rotate the nursing staff assigned to the client frequently.
Correct Answer: B
Rationale: The best nursing intervention for a client with borderline personality disorder expressing fear of abandonment is to set limits on the client's behavior and enforce them consistently. This approach helps establish boundaries and provides a sense of security for the client. Choice A may provide temporary reassurance but does not address the core issue or help the client develop coping strategies. Choice C is important but should be accompanied by setting limits to address the underlying fear of abandonment. Choice D of rotating staff frequently can exacerbate the client's fear of abandonment by reinforcing the idea of being left.
A client who has been admitted to the psychiatric unit tells the nurse, 'My problems are so bad that no one can help me.' Which response is best for the nurse to make?
- A. How can I help?
- B. Things probably aren't as bad as they seem right now.
- C. Let's talk about what is right with your life.
- D. I hear how miserable you are, but things will get better soon.
Correct Answer: A
Rationale: Offering self shows empathy and caring (A) and is the best choice provided. (B) dismisses the client's feelings and reality. (C) avoids addressing the client's concerns directly and may come across as invalidating. Although (D) starts with acknowledging the client's feelings, the second part about things getting better soon can be perceived as offering false reassurance, which is not recommended in therapeutic communication.
A client who has recently been diagnosed with schizophrenia tells the LPN/LVN, 'I hear voices telling me to hurt myself.' What is the most appropriate nursing action?
- A. Encourage the client to ignore the voices.
- B. Tell the client that the voices will go away with medication.
- C. Monitor the client for signs of self-harm.
- D. Refer the client for a psychiatric evaluation.
Correct Answer: D
Rationale: The correct answer is to refer the client for a psychiatric evaluation. The client's statement indicating hearing voices telling them to hurt themselves is a serious concern and suggests a risk for self-harm. Referring the client for a psychiatric evaluation is crucial for further assessment and intervention by mental health professionals. Choice A is incorrect because ignoring the voices may not address the client's safety. Choice B is incorrect as it oversimplifies the situation and does not address the immediate risk. Choice C is not as comprehensive as referring for a psychiatric evaluation, which is necessary in this situation.