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A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. What action should the nurse implement?
- A. Attempt to ask the client simple questions.
- B. Postpone the client interview until the next day.
- C. Ask another nurse to talk with the client.
- D. Document the client's paranoid behavior.
Correct Answer: A
Rationale: When a client is guarded, suspicious, and resistant to talking, it is important for the nurse to attempt to ask the client simple questions. Simple questions can help build rapport, establish trust, and create a non-threatening environment. This approach may ease the client into more detailed discussions while reducing feelings of suspicion. Postponing the interview may increase the client's anxiety and distrust, while asking another nurse to talk with the client may disrupt continuity of care and the establishment of a therapeutic relationship. Documenting the client's behavior is important for the client's medical record, but it should not be the first action taken in this situation.
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A client who has recently been diagnosed with schizophrenia tells the LPN/LVN, 'I hear voices telling me to hurt myself.' What is the most appropriate nursing action?
- A. Encourage the client to ignore the voices.
- B. Tell the client that the voices will go away with medication.
- C. Monitor the client for signs of self-harm.
- D. Refer the client for a psychiatric evaluation.
Correct Answer: D
Rationale: The correct answer is to refer the client for a psychiatric evaluation. The client's statement indicating hearing voices telling them to hurt themselves is a serious concern and suggests a risk for self-harm. Referring the client for a psychiatric evaluation is crucial for further assessment and intervention by mental health professionals. Choice A is incorrect because ignoring the voices may not address the client's safety. Choice B is incorrect as it oversimplifies the situation and does not address the immediate risk. Choice C is not as comprehensive as referring for a psychiatric evaluation, which is necessary in this situation.
A 19-year-old female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other clients on a psychiatric unit. What action should the nurse take?
- A. Encourage the client's self-motivation by asking her to assist with other activities.
- B. Provide an alternative suggestion for the client to participate in the unit's activities.
- C. Allow the client to serve dinner trays to other clients but monitor closely for any signs of distress.
- D. Explain to the client that she needs to focus on her own recovery and cannot participate in serving dinner trays.
Correct Answer: B
Rationale: Clients with anorexia should not be allowed to plan or prepare food for unit activities, as this can reinforce their perception of self-control. Allowing the client to serve dinner trays (C) may trigger distress or unhealthy behaviors. Therefore, it is best to provide an alternative suggestion for the client to participate in the unit's activities (B). Encouraging the client to assist with other activities (A) may inadvertently reinforce negative behaviors related to food. Explaining to the client that she cannot participate in serving dinner trays (D) without offering an alternative does not address the client's desire to help and may lead to feelings of rejection.
An adolescent who attempted suicide with a drug overdose arrives in the emergency department with an empty 30-tablet bottle of acetaminophen (Tylenol). Which action should the nurse implement?
- A. Administer acetylcysteine (Mucomyst).
- B. Monitor cardiac rhythm for flat T waves.
- C. Check both serum AST and ALT levels.
- D. Prepare to administer Syrup of Ipecac.
Correct Answer: A
Rationale: The correct action for the nurse to implement is to administer acetylcysteine (Mucomyst). Acetylcysteine is the antidote for acetaminophen overdose and should be administered promptly to prevent liver damage. Monitoring cardiac rhythm for flat T waves (Choice B) is not specific to acetaminophen overdose and is more related to cardiac conditions. Checking serum AST and ALT levels (Choice C) may be done later but is not the initial priority in this situation. Similarly, preparing to administer Syrup of Ipecac (Choice D) is not recommended anymore in cases of overdose as it can cause more harm.
A client with schizophrenia is experiencing auditory hallucinations that command him to harm himself. What is the nurse's priority action?
- A. Ensure the client is not left alone.
- B. Document the content of the hallucinations.
- C. Administer PRN antipsychotic medication.
- D. Encourage the client to ignore the voices.
Correct Answer: A
Rationale: The correct answer is to ensure the client is not left alone. When a client with schizophrenia is having auditory hallucinations that command self-harm, the priority is to ensure the client's safety. Leaving the client alone may increase the risk of self-harm. Documenting the content of the hallucinations (choice B) is important but not the priority when immediate safety is a concern. Administering PRN antipsychotic medication (choice C) may be necessary but is not the priority over ensuring the client's immediate safety. Encouraging the client to ignore the voices (choice D) is not as effective as ensuring the client's safety by being present and providing support.
During initial assessment of the teenager, what information is most important for the nurse to obtain from the parents?
- A. If he has seemed depressed recently.
- B. If a drug overdose has ever occurred before.
- C. If he might have taken any other drugs.
- D. If he has a desire to quit taking drugs.
Correct Answer: C
Rationale: The correct answer is C. It's crucial to determine if the teenager might have taken other substances besides the pain pills mentioned by the mother. This information is vital for effective treatment because knowing the full scope of substances involved helps in managing potential interactions, side effects, and the overall condition of the patient. Options A, B, and D are not as critical in the immediate assessment compared to knowing if the teenager has ingested any other drugs.