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A client engages in repeated checks of door and window locks and behavior that prevents the client from arriving on time and interfering with the ability to function effectively. Which action should the nurse take?
- A. Determine the type and size of the locks
- B. Plan a list of activities to be carried out daily
- C. Discuss checking the time frequently
- D. Ask the client why the locks are checked so frequently
Correct Answer: B
Rationale: Planning a list of daily activities helps establish a structured routine, reducing time spent on compulsive checking and promoting effective functioning. Determining lock types is irrelevant. Discussing time-checking does not address lock-checking. Asking 'why' may increase frustration, as compulsive behaviors are anxiety-driven.
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When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?
- A. Involve client in daily exercise program
- B. Ask the client to describe her depression
- C. Spend time sitting in silence with client
- D. Observe for signs of possible psychosis
Correct Answer: C
Rationale: Spending time sitting in silence with the client provides a supportive presence without pressure for immediate responses, which is helpful for depression-related delays in communication. Exercise may be beneficial but does not address delayed responses directly. Asking about depression is useful for assessment but not immediate needs. Observing for psychosis is not indicated unless other symptoms are present.
A young female client is admitted to the emergency room because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record as the client's chief complaint?
- A. Client claims that she was forced to participate in sexual intercourse
- B. Client reported that she had sexual relations against her will
- C. Client has been sexually assaulted
- D. Client states, 'My date raped me tonight'
Correct Answer: D
Rationale: Client states, 'My date raped me tonight' is the most accurate and objective, using the client's own words to document the chief complaint without implying doubt ('claims') or minimizing the trauma. 'Sexual assault' is accurate but less specific.
A nurse is caring for a client:
The client has returned to work at an accounting firm and has started going to a grief support group. She reports she is seeking care from a healthcare professional because her father is worried about her. The client says she only gets 2 to 3 hours of sleep due to nightmares about the crash. She informs that exercising right after work helps her get better sleep and to relax. She feels that she is "jumpy" after the accident, especially when she is in the car. She also stated, "I feel so sad that I can't seem to feel anything at all." In addition to her father, the client has a large family and friend support system. She denies alcohol or drug use.
Click to highlight the areas that the nurse should react to immediately. The client has returned to work at an accounting firm and has started going to a grief support group. She reports she is seeking care from a healthcare provider because her father is worried about her. The client says she only gets 2 to 3 hours of sleep due to nightmares about the crash. She informs that exercising right after work helps her get better sleep and to relax. She feels that she is 'jumpy' after the accident, especially when she is in the car. She also stated, 'I feel so sad that I can't seem to feel anything at all.' In addition to her father, the client has a large family and friend support system. She denies alcohol or drug use.
- A. she only gets 2 to 3 hours of sleep
- B. She feels that she is 'jumpy' after the accident
- C. I feel so sad that I can't seem to feel anything at all
Correct Answer: A,B,C
Rationale: Sleep disturbances, heightened startle response ('jumpy'), and sadness/numbness indicate possible acute stress or PTSD, requiring immediate intervention like creating a safe environment and mental health referral. These symptoms suggest significant distress post-trauma.
The nurse has received a new prescription for the client to begin taking sertraline. Prior to administering the initial dose of sertraline, it is most important for the nurse to obtain which information?
- A. Any history of heart disease
- B. Familial history of mental illness
- C. Medication history
- D. Current weight
Correct Answer: C
Rationale: Obtaining a thorough medication history is essential to identify potential drug interactions, allergies, or contraindications for sertraline. Heart disease history is relevant but less critical. Familial mental illness history is not immediately necessary. Weight does not typically affect sertraline dosing.
The nurse is performing the admission assessment for a client with schizophrenia in an acute care inpatient facility. The nurse should identify which observed behavior is characteristic of schizophrenia?
- A. Responds with illogical answers to questions
- B. Admits to frequently thinking about committing suicide
- C. Describes times of depression followed by feelings of euphoria
- D. Exhibits compulsive, ritualistic behaviors
Correct Answer: A
Rationale: Responding with illogical answers indicates disorganized thinking, a hallmark of schizophrenia during psychosis. Suicide thoughts are not specific to schizophrenia. Depression and euphoria suggest bipolar disorder. Compulsive behaviors are more typical of OCD.