Nokea
A client is admitted to the mental health unit and reports taking extra antianxiety medication because, "I'm so stressed out. I just wanted to go sleep." The nurse should plan one-on-one observation of the client based on which statement?
- A. What should I do? Nothing seems to help.
- B. I have been so tired lately and needed to sleep.
- C. I really think that I don't need to be here.
- D. I don't want to talk. Nothing matters anymore.
Correct Answer: D
Rationale: The client's statement of not wanting to talk and feeling that nothing matters anymore is indicative of severe depression or a risk for self-harm. This warrants immediate attention and one-on-one observation to ensure the client's safety. Choices A, B, and C do not express the same level of concerning behavior and do not imply an immediate risk to the client's well-being.
You may also like to solve these questions
The nurse is developing unit policies that will include nursing guidelines for maintaining a therapeutic milieu. Which interventions should be included when providing a therapeutic milieu in an inpatient setting?
- A. Opportunities to contribute to one's treatment plan.
- B. One-on-one dialogue sessions with the therapist.
- C. Regularly scheduled unit activities for peer interaction.
- D. Home visits to reintegrate into the family.
Correct Answer: C
Rationale: The nurse is responsible for maintaining a therapeutic milieu in an inpatient setting, which involves creating a secure and structured environment that promotes client safety and offers opportunities for clients to learn healthy coping skills. Regularly scheduled unit activities for peer interaction help foster socialization, support, and a sense of community among clients. Choices A and B are valuable interventions in mental health care but do not directly relate to creating a therapeutic milieu in an inpatient setting. Choice D, home visits, would typically occur post-discharge and focus on community reintegration, rather than maintaining a therapeutic milieu within the inpatient setting.
A client who is admitted to the mental health unit reports shortness of breath and dizziness. The client tells the nurse, "I feel like I'm going to die." Which nursing problem should the nurse include in this client's plan of care?
- A. Mood disturbance
- B. Moderate anxiety
- C. Altered thoughts
- D. Social isolation
Correct Answer: B
Rationale: The correct answer is B: Moderate anxiety. When a client presents with symptoms such as shortness of breath, dizziness, and a fear of dying, it indicates moderate anxiety. Anxiety can manifest physically with symptoms like these. Mood disturbance (choice A) refers to a change in mood, while altered thoughts (choice C) relate to cognitive changes. Social isolation (choice D) involves a lack of social interaction, which is not the primary concern in this scenario where the client is experiencing acute anxiety symptoms.
When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?
- A. Impaired comfort.
- B. Risk for injury.
- C. Ineffective breathing pattern.
- D. Ineffective coping.
Correct Answer: C
Rationale: Ineffective breathing pattern is the highest priority nursing problem in this scenario because aspiration of a caustic material can lead to serious airway and respiratory issues. This poses an immediate threat to the client's life and requires urgent intervention to ensure adequate oxygenation and ventilation. The other options, such as Impaired comfort, Risk for injury, and Ineffective coping, are important but are secondary concerns compared to the critical nature of respiratory compromise in this situation.
A client with depression remains in bed most of the day, declines activities, and refuses meals. Which nursing problem has the greatest priority for this client?
- A. Loss of interest in diversional activities.
- B. Social isolation.
- C. Refusal to address nutritional needs.
- D. Low self-esteem.
Correct Answer: C
Rationale: The correct answer is C: 'Refusal to address nutritional needs.' In this scenario, the client's refusal to eat and address their nutritional needs poses an immediate threat to their physical health. Without proper nutrition, the client is at risk of malnutrition and its associated complications. While addressing social isolation, low self-esteem, and loss of interest in diversional activities are important aspects of holistic care for a client with depression, ensuring proper nutrition takes precedence due to the critical impact it has on the client's physical well-being. Therefore, the priority is to address the client's refusal to eat and address their nutritional needs to prevent further deterioration of their health.
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 acknowledging 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 best intervention for a male client with schizophrenia displaying echolalia, which is disruptive to others, is for the nurse to escort the client to his room. Echolalia, the constant repetition of others' words, can be disruptive in a communal setting. By guiding the client to a private space like his room, the nurse helps manage the behavior without isolating or medicating the client unnecessarily. Avoiding acknowledging the behavior (Choice A) does not address the issue, isolating the client (Choice B) may exacerbate feelings of exclusion, and administering a PRN sedative (Choice C) should be reserved for situations where there is imminent risk or severe agitation, not for managing echolalia.