Nokea
A charge nurse is discussing suicide interventions with nursing staff. Which of the following should the nurse identify as an example of secondary intervention?
- A. Providing support for family and friends following a suicide.
- B. Identifying individuals who are at higher risk for attempting suicide.
- C. Recognizing the warning signs of suicide.
- D. Performing life-saving measures following a suicide attempt.
Correct Answer: D
Rationale: Secondary intervention involves direct care during a suicide crisis, such as life-saving measures.
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A nurse is assigning a room to a client who is experiencing a manic episode. Which of the following is the most appropriate room selection?
- A. A room adjacent to the nursing station
- B. A room without a window
- C. A room with dim lighting
- D. A room containing personal belongings
Correct Answer: A
Rationale: A room close to the nursing station allows for close monitoring and quick intervention if necessary.
A nurse is caring for a client who has bipolar disorder and a new prescription for valproate. Which of the following instructions should the nurse give the client about the use of this medication?
- A. Thyroid function tests should be performed every 6 months.
- B. A pretreatment electroencephalogram (EEG) will be done.
- C. Liver function tests should be monitored.
- D. High serum sodium levels can cause toxic levels of valproate.
Correct Answer: C
Rationale: Valproate is metabolized in the liver, requiring regular liver function monitoring.
A nurse is caring for a client who has been diagnosed with obsessive-compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?
- A. Limit the amount of time available to interact with others
- B. Focus attention on meaningful tasks
- C. Manipulate and control others’ behaviors
- D. Decrease anxiety to a tolerable level
Correct Answer: D
Rationale: The correct answer is D: Decrease anxiety to a tolerable level. In OCD, repetitive behaviors like picking up after others serve to reduce anxiety stemming from obsessive thoughts. This behavior acts as a coping mechanism to alleviate distress. Choice A is incorrect as the behavior is driven by anxiety, not a desire to limit interaction time. Choice B is incorrect as the behavior is not necessarily meaningful but rather a compulsive act. Choice C is incorrect as the behavior is self-directed, not aimed at controlling others.
A nurse is assessing an adolescent client who has anorexia nervosa. Which of the following client statements is a sign of cognitive distortion?
- A. "I like to cut my food into small pieces."
- B. "I really need to get into shape."
- C. "If I eat one piece of candy, I may as well eat ten."
- D. "I can't afford to gain weight."
Correct Answer: C
Rationale: Cognitive distortions involve irrational thought patterns, such as all-or-nothing thinking.
A nurse is caring for a client who attacked one of her friends and is admitted to the psychiatric unit. Which of the following actions should the nurse take first?
- A. Establish a client relationship.
- B. Explain to the client that the behavior was unacceptable.
- C. Explore the truth of the client’s statements.
- D. Set behavioral limits for the client.
Correct Answer: D
Rationale: Setting behavioral limits helps establish expectations for the client’s conduct in the unit.