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A client diagnosed with major depressive disorder refuses to get out of bed, eat, or participate in group therapy. Which intervention is most important for the nurse to implement?
- A. Offer the client high-calorie snacks and frequent small meals.
- B. Ask the client why they are not participating in therapy.
- C. Sit with the client and offer support without demanding participation.
- D. Encourage the client to discuss their feelings of hopelessness.
Correct Answer: C
Rationale: The correct answer is C because sitting with the client and offering support without demanding participation is crucial in building trust and rapport. This approach respects the client's autonomy and allows them to feel supported without pressure. It also creates a safe space for the client to open up when they are ready.
Explanation for why the other choices are incorrect:
A: Offering high-calorie snacks and frequent small meals does not address the core issue of the client's refusal to participate in therapy.
B: Asking the client why they are not participating in therapy may come off as confrontational and could further discourage them from opening up.
D: Encouraging the client to discuss their feelings of hopelessness may be overwhelming for them at this stage and could lead to resistance.
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A highly successful individual presents to the community mental health center complaining of sleeplessness and anxiety over their financial status. What action should the nurse take to assist this client in diminishing their anxiety?
- A. Encourage them to initiate daily rituals.
- B. Reinforce the reality of their financial situation.
- C. Direct them to drink a glass of red wine at bedtime.
- D. Teach them to limit sugar and caffeine intake.
Correct Answer: D
Rationale: The correct answer is D: Teach them to limit sugar and caffeine intake.
Rationale:
1. Sugar and caffeine intake can exacerbate anxiety and interfere with sleep due to their stimulant effects.
2. Limiting these substances can help regulate the body's energy levels and reduce anxiety symptoms.
3. By teaching the client to limit sugar and caffeine intake, the nurse is addressing the root causes of the client's sleeplessness and anxiety.
Summary:
A: Encouraging daily rituals may provide structure but does not directly address the physiological effects of sugar and caffeine on anxiety.
B: Reinforcing the reality of the financial situation may increase anxiety rather than alleviate it.
C: Drinking red wine at bedtime is not a recommended solution for managing anxiety and sleeplessness.
The client with newly diagnosed osteoporosis is being taught by the nurse about dietary modifications. Which instruction should the nurse include?
- A. Increase your intake of high-calcium foods.
- B. Limit your intake of vitamin D-rich foods.
- C. Avoid foods high in phosphorus.
- D. Increase your intake of high-sodium foods.
Correct Answer: A
Rationale: The correct answer is A: Increase your intake of high-calcium foods. Osteoporosis is a condition characterized by low bone density, and calcium is essential for bone health. Increasing calcium intake can help strengthen bones and prevent further bone loss. Foods high in calcium, such as dairy products, leafy green vegetables, and fortified foods, are beneficial for individuals with osteoporosis.
Summary of other choices:
B: Limiting intake of vitamin D-rich foods is not advised, as vitamin D plays a crucial role in calcium absorption and bone health.
C: Avoiding foods high in phosphorus is not necessary, as phosphorus is also important for bone health and overall body function.
D: Increasing intake of high-sodium foods is not recommended, as high sodium intake can lead to calcium loss from the bones, worsening osteoporosis.
Because the census is currently low in the Obstetrics (OB) unit, one of the nurses is sent to work on a medical-surgical unit for the day, or until the OB unit becomes busy. Which client assessment is best for the charge nurse to assign to the OB nurse?
- A. An adult who had a colon resection yesterday and has an IV.
- B. An older adult who has a fever of unknown origin.
- C. A woman who had an acute brain attack (stroke, CVA) 6 hours ago.
- D. A teenager with a femoral fracture who is in traction.
Correct Answer: A
Rationale: The correct answer is A because the OB nurse's background in obstetrics makes them most suitable to care for a post-operative patient with an IV. This assignment aligns with the nurse's skill set and ensures safe and competent care. Choices B, C, and D involve medical-surgical conditions that may require specialized knowledge and skills beyond the OB nurse's expertise, potentially compromising patient care. Assigning the OB nurse to care for a post-operative patient with an IV is the most appropriate choice given the circumstances.
A 9-year-old female client was recently diagnosed with diabetes mellitus. Which symptom will her parents most likely report?
- A. Refuses to eat her favorite meals at home.
- B. Drinks more soft drinks than previously.
- C. Voids only one or two times per day.
- D. Gained 10 pounds within one month.
Correct Answer: B
Rationale: The correct answer is B because increased thirst and drinking more fluids than usual is a common symptom of diabetes mellitus due to high blood sugar levels causing dehydration. Refusing to eat favorite meals (choice A) is not a typical symptom. Voids only one or two times per day (choice C) is more related to urinary issues than diabetes. Gaining 10 pounds within one month (choice D) is not a specific symptom of diabetes and can be attributed to various factors.
When evaluating a client's understanding of wearing a Holter monitor, which statement made by the client would indicate to the nurse that the client understands the procedure?
- A. I must record any symptoms occurring with my activity.
- B. I am not looking forward to staying in bed for 24 hours.
- C. I really am dreading the frequent blood drawing.
- D. I know that I shouldn't get close to my microwave oven.
Correct Answer: A
Rationale: The correct answer is A because it demonstrates the client understands the purpose of wearing a Holter monitor—to record symptoms related to activity. This shows the client comprehends the importance of monitoring symptoms accurately. Choices B, C, and D are incorrect because they do not relate to the purpose of wearing a Holter monitor or indicate an understanding of the procedure. B focuses on personal preference, C on unrelated procedures, and D on irrelevant safety precautions.