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A client is admitted for bipolar disorder and alcohol withdrawal, depressive phase. Based on which assessment finding will the RN withhold the clonidine (Catapres) prescription?
- A. Blood pressure readings of 90/62 mmHg to 92/58 mmHg.
- B. Pulse rate of 68-78 BPM.
- C. Temperature of 99.5-99.7 F.
- D. Respiration rate of 24 breaths per minute.
Correct Answer: A
Rationale: The correct answer is A. Clonidine is a medication commonly prescribed for managing symptoms of alcohol withdrawal. Since it can lower blood pressure, it is crucial to monitor the client's blood pressure regularly. In this case, the client's blood pressure readings of 90/62 mmHg to 92/58 mmHg are low, indicating hypotension. Administering clonidine in this situation can further decrease blood pressure, potentially causing adverse effects like dizziness, light-headedness, or even fainting. Therefore, the RN should withhold the clonidine prescription to prevent exacerbating hypotension. Choices B, C, and D are within normal ranges and do not contraindicate the use of clonidine in this scenario.
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A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What is the priority nursing problem for admission to the psychiatric unit?
- A. Ineffective sexual patterns.
- B. Impaired environmental interpretation.
- C. Disturbed sensory perception.
- D. Compromised family coping.
Correct Answer: C
Rationale: The correct answer is C: Disturbed sensory perception. The client's delusions and false beliefs indicate a break from reality, which is a hallmark symptom of disturbed sensory perception. This poses a risk to the client's safety and well-being. Ineffective sexual patterns (choice A) and compromised family coping (choice D) may be secondary to the primary issue of distorted perceptions. Impaired environmental interpretation (choice B) is less relevant as the client's issues are more internal. Overall, addressing the disturbed sensory perception is the priority to ensure the client's safety and initiate appropriate treatment.
The nurse leading a group session of adolescent clients gives the members a handout about anger management. One of the male clients is fidgety, interrupts peers when they try to talk, and talks about his pets at home. What nursing action is best for the nurse to take?
- A. Give the client permission to leave and return in 10 minutes.
- B. Explore the client’s feelings about his pets and home life.
- C. Encourage his peers to help involve him in the activity.
- D. Redirect him by encouraging him to read from the handout.
Correct Answer: D
Rationale: The correct answer is D: Redirect him by encouraging him to read from the handout. This option addresses the client's behavior by redirecting his focus back to the group activity. By encouraging him to read from the handout, the nurse provides a constructive way for the client to engage with the material and participate in the session. This approach helps the client stay on track with the intended purpose of the group session, which is anger management.
Other choices are incorrect:
A: Giving the client permission to leave may reinforce disruptive behavior.
B: Exploring the client's feelings about his pets may not address the immediate issue of his behavior.
C: Involving peers may not effectively address the client's disruptive behavior.
Overall, option D is the most appropriate as it directly addresses the client's behavior and redirects him in a positive way.
A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the nurse to implement?
- 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: The correct answer is D: Escort the client to his room. Echolalia is a common symptom of schizophrenia, where the individual repeats words or phrases they hear. Escorting the client to his room provides a safe and appropriate environment for the client to engage in the behavior without bothering other clients. Avoiding recognition (choice A) may not address the behavior and could lead to escalation. Isolating the client (choice B) may be seen as punitive and could worsen the client's symptoms. Administering a sedative (choice C) should be a last resort and not the initial intervention for managing echolalia.
James is a 42-year-old patient with schizophrenia. He approaches you as you arrive for day shift and anxiously reports, “Last night, demons came to my room and tried to rape me.†Which response would be most therapeutic?
- A. There are no such things as demons. What you saw were hallucinations.
- B. It is not possible for anyone to enter your room at night. You are safe here.
- C. You seem very upset. Please tell me more about what you experienced last night.
- D. That must have been very frightening, but we’ll check on you at night and you’ll be safe.
Correct Answer: C
Rationale: The correct answer is C because it demonstrates empathy and active listening. By acknowledging James's feelings and inviting him to share more about his experience, the response validates his emotions and fosters trust. This approach helps build a therapeutic relationship and allows for a deeper exploration of his hallucinations. Options A and B invalidate James's experience and may increase his distress. Option D offers reassurance but lacks the immediate emotional support James needs.
April, a 10-year-old admitted to inpatient pediatric care, has been getting more and more wound up and is losing self-control in the day room. Time-out does not appear to be an effective tool for April to engage in self-reflection. April’s mother admits to putting her in time-out up to 20 times a day. The nurse recognizes that:
- A. Time-out is an important part of April’s baseline discipline.
- B. Time-out is no longer an effective therapeutic measure.
- C. April enjoys time-out, and acts out to get some alone time.
- D. Time-out will need to be replaced with seclusion and restraint.
Correct Answer: B
Rationale: The correct answer is B: Time-out is no longer an effective therapeutic measure. In this scenario, April's escalating behavior and the ineffectiveness of time-out suggest that it is not addressing the underlying issues causing her behavior. Continuous use of time-out can lead to it losing its effectiveness and may not promote self-reflection. April's behavior worsening despite frequent use of time-out indicates the need for a different approach to address her needs.
Choices A, C, and D are incorrect because they do not address the situation at hand. Choice A assumes time-out is still effective despite evidence to the contrary. Choice C assumes April enjoys time-out, which is not supported by the information given. Choice D suggests a drastic and inappropriate measure of seclusion and restraint, which should only be used as a last resort in emergency situations.