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A client is admitted with a diagnosis of depression. The nurse knows that which characteristic is most indicative of depression?
- A. Grandiose ideation.
- B. Self-destructive thoughts.
- C. Suspiciousness of others.
- D. A negative view of self and the future.
Correct Answer: D
Rationale: A negative view of self and the future (D) is a prominent characteristic of depression. It reflects the core symptoms of low self-esteem and hopelessness that are commonly associated with this condition. Grandiose ideation (A) and suspiciousness of others (C) are more indicative of other mental health disorders like paranoia. While self-destructive thoughts (B) can be present in depression, they are not as specific and common as the negative self-view and hopelessness, making option (D) the most indicative characteristic of depression.
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In a mental health unit of a hospital, a LPN/LVN is leading a group psychotherapy session. What is the nurse's role in the termination stage of group development?
- A. Encourage problem solving
- B. Encourage accomplishment of the group's work
- C. Acknowledge the contributions of each group member
- D. Encourage members to become acquainted with one another
Correct Answer: C
Rationale: During the termination stage of group development in psychotherapy, the nurse's role is to acknowledge the contributions of each group member. This action helps to close the group on a positive note, reinforcing the therapeutic experience. Choice A, encouraging problem-solving, is more relevant in the earlier stages of group development. Choice B, encouraging the accomplishment of the group's work, is important throughout the group process but is not specific to the termination stage. Choice D, encouraging members to become acquainted with one another, is more aligned with the initial stages of group formation rather than the termination stage.
During a mental status exam, what factor should the nurse remember when assessing a client's intelligence?
- A. Acute psychiatric illnesses can impair intelligence
- B. Intelligence can be influenced by social and cultural beliefs
- C. Poor concentration skills suggest limited intelligence
- D. The inability to think abstractly indicates limited intelligence
Correct Answer: B
Rationale: The correct answer is B. Intelligence is indeed influenced by social and cultural beliefs. It is essential to recognize that intelligence is not solely determined by innate abilities but can also be shaped by various external factors such as cultural background, education, and social environment. Choices A, C, and D are incorrect because acute psychiatric illnesses do not necessarily impair intelligence, poor concentration skills do not always suggest limited intelligence, and the inability to think abstractly alone does not always indicate limited intelligence.
A female client refuses to take an oral hypoglycemic agent because she believes that the drug is being administered as part of an elaborate plan by the Mafia to harm her. Which nursing intervention is most important to include in this client's plan of care?
- A. Reassure the client that no one will harm her while she is in the hospital.
- B. Ask the healthcare provider to give the client the medication.
- C. Explain the importance of taking the diabetic medication.
- D. Reassess the client's mental status for thought processes and content.
Correct Answer: D
Rationale: Reassessing the client's mental status is the most important intervention as it is crucial to address the client's delusional thinking. By assessing the client's thought processes and content, the nurse can gain insight into the client's beliefs and tailor interventions accordingly. Reassuring the client that no harm will come to her, asking the healthcare provider to give the medication, or simply explaining the importance of taking the medication may not effectively address the underlying issue of delusional beliefs.
A 46-year-old female client has been on antipsychotic neuroleptic medication for the past three days. She has had a decrease in psychotic behavior and appears to be responding well to the medication. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. Which action will the nurse initiate?
- A. Place the client on seizure precautions and monitor closely.
- B. Immediately transfer the client to the ICU.
- C. Report the symptoms to the charge nurse and document in the client's chart.
- D. No action is required at this time as these are known side effects of such medications.
Correct Answer: B
Rationale: These symptoms are indicative of neuroleptic malignant syndrome (NMS), which is a severe and life-threatening reaction to neuroleptic drugs. The major symptoms include fever, rigidity, autonomic instability, and encephalopathy. Respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure can lead to death. This is an emergency situation requiring immediate critical care, thus the correct action is to transfer the client to the ICU (B). Seizure precautions (A) are not relevant in this scenario. Merely describing the symptoms to the charge nurse and documenting them (C) or taking no action assuming these are common side effects (D) fail to address the critical nature of the situation and the urgency of immediate intervention.
A client with Alzheimer's disease is becoming increasingly agitated and combative in the late afternoon. What is the most appropriate intervention?
- A. Offer a sedative medication to calm the client.
- B. Encourage the client to rest in a quiet, low-stimulation environment.
- C. Use reality orientation to reduce confusion.
- D. Engage the client in physical activity to reduce agitation.
Correct Answer: B
Rationale: Encouraging the client to rest in a quiet, low-stimulation environment is the most appropriate intervention for a client with Alzheimer's disease who is becoming agitated and combative in the late afternoon. This approach helps reduce agitation and prevent overstimulation, providing a calming and soothing environment for the client. Offering a sedative medication (Choice A) should be avoided as it may have side effects and should only be considered as a last resort. Reality orientation (Choice C) may increase confusion and distress in clients with advanced Alzheimer's disease. Engaging the client in physical activity (Choice D) could potentially escalate the agitation rather than reduce it in this scenario.