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A client is experiencing a moderate level of anxiety. Which is an example of an appropriate nursing intervention?
- A. Allow the client to pace in a safe environment.
- B. Encourage the client to discuss feelings.
- C. Help the client identify the cause of anxiety.
- D. Provide a distraction for the client.
Correct Answer: A
Rationale: Allowing the client to pace in a safe environment is an appropriate nursing intervention for managing moderate anxiety levels. Allowing pacing provides the client with a physical outlet for their anxiety and can help them release nervous energy without increasing distress. It promotes movement and can aid in reducing feelings of restlessness or agitation. Encouraging the client to discuss feelings (Choice B) is more suitable for addressing emotional aspects of anxiety rather than providing an immediate physical outlet. Helping the client identify the cause of anxiety (Choice C) may be more appropriate for long-term management but may not address the immediate need for physical release. Providing a distraction (Choice D) may not directly address the physical needs associated with moderate anxiety levels.
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Which client action is an example of the defense mechanism of sublimation?
- A. A woman channels her energy into a new hobby after a breakup.
- B. A man redirects his anger from work into a workout routine.
- C. A student focuses on studying to avoid thinking about a recent argument.
- D. An athlete channels competitive impulses into a successful sports career.
Correct Answer: B
Rationale: Sublimation is a defense mechanism where unacceptable impulses are redirected into socially acceptable activities. In this scenario, the man redirects his anger from work into a workout routine, which is a positive and constructive way of managing his emotions. Choices A, C, and D do not fully align with sublimation as they do not involve redirecting unacceptable impulses into socially acceptable outlets, unlike the man's action in choice B.
A healthcare provider is caring for a client diagnosed with schizophrenia. Which intervention is most appropriate to address the client's delusions?
- A. Challenge the client's delusions directly.
- B. Provide evidence to disprove the delusions.
- C. Acknowledge the client's feelings without reinforcing the delusions.
- D. Ignore the client's delusions.
Correct Answer: C
Rationale: When caring for a client with schizophrenia experiencing delusions, the most appropriate intervention is to acknowledge the client's feelings without reinforcing the delusions. This approach helps maintain trust and communication, fostering a therapeutic relationship. Challenging the delusions directly can lead to increased distress and resistance from the client. Providing evidence to disprove the delusions may not be effective due to the deeply ingrained nature of the client's beliefs. Ignoring the delusions may make the client feel dismissed or unheard, which can hinder the therapeutic process.
Which client statement indicates an understanding of the education provided about the antidepressant medication sertraline (Zoloft)?
- A. I should take this medication on an empty stomach.
- B. It may take several weeks for this medication to be effective.
- C. I can stop taking this medication when I feel better.
- D. I should avoid taking this medication with other medications.
Correct Answer: B
Rationale: Choice B is the correct answer. It is crucial for clients to understand that sertraline (Zoloft) may take several weeks to show its full effects. Patients should be informed about this delay in onset of action to set realistic expectations and adhere to the treatment plan. This education helps prevent premature discontinuation of the medication due to perceived lack of efficacy. Choices A, C, and D are incorrect. Choice A is inaccurate because sertraline (Zoloft) should be taken with food to reduce the risk of gastrointestinal side effects. Choice C is incorrect because abruptly stopping the medication can lead to withdrawal symptoms and worsening of the condition. Choice D is inaccurate as there are specific medications that should be avoided with sertraline, but a general statement to avoid all other medications is overly broad and not necessary.
A client with bipolar disorder is in the manic phase. Which nursing intervention should the nurse implement to ensure the client's safety?
- A. Provide a structured environment with minimal stimuli.
- B. Encourage the client to participate in group activities.
- C. Monitor the client closely for signs of exhaustion.
- D. Encourage the client to rest and sleep as needed.
Correct Answer: A
Rationale: During the manic phase of bipolar disorder, individuals may engage in impulsive behaviors that can put them at risk of harm. Providing a structured environment with minimal stimuli can help reduce the risk of injury by minimizing triggers for impulsive actions. This intervention promotes a safe and controlled setting for the client, which is crucial in managing the symptoms of mania. Encouraging the client to participate in group activities (Choice B) may increase stimuli and potentially exacerbate manic symptoms. Monitoring for signs of exhaustion (Choice C) is important but does not directly address the safety concerns related to impulsive behaviors during mania. Encouraging the client to rest and sleep as needed (Choice D) may be challenging during the manic phase when individuals typically experience decreased need for sleep.
A client has been diagnosed with borderline personality disorder. Which behavior is characteristic of this disorder?
- A. Excessive need for attention
- B. Instability in relationships
- C. Fear of abandonment
- D. Lack of interest in activities
Correct Answer: B
Rationale: The correct answer is B: Instability in relationships. Individuals with borderline personality disorder often exhibit instability in their relationships, characterized by intense and unstable interpersonal connections, oscillating between idealization and devaluation. This pattern can lead to frequent conflicts, dramatic emotional shifts, and difficulties maintaining stable relationships. Choices A, C, and D are incorrect. While individuals with borderline personality disorder may also have an excessive need for attention, fear of abandonment, or lack of interest in activities, the hallmark feature defining this disorder is the instability in relationships.