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A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care?
- A. Excessive CNS stimulation will be reduced.
- B. Co-dependent behaviors will be decreased.
- C. Client's level of consciousness will increase.
- D. Client will not demonstrate cross-addiction.
Correct Answer: A
Rationale: The correct answer is A: 'Excessive CNS stimulation will be reduced.' During benzodiazepine withdrawal, the priority is to manage symptoms such as CNS hyperactivity, which can include agitation, anxiety, and seizures. Substitution therapy aims to minimize these withdrawal symptoms by providing a safer alternative to the benzodiazepine. Options B, C, and D are not the highest priority during benzodiazepine withdrawal. Decreasing co-dependent behaviors, increasing the client's level of consciousness, and preventing cross-addiction are important aspects of care but are not as critical as managing the potentially severe CNS stimulation.
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What intervention is likely to be most effective in returning a middle-aged adult with major depressive disorder who suffers from psychomotor retardation, hypersomnia, and amotivation to a normal level of functioning?
- A. Encourage the client to exercise.
- B. Suggest that the client develop a list of pleasurable activities.
- C. Provide education on methods to enhance sleep.
- D. Teach the client to develop a plan for daily structured activities.
Correct Answer: D
Rationale: The most effective intervention for a middle-aged adult with major depressive disorder experiencing psychomotor retardation, hypersomnia, and amotivation is to teach the client to develop a plan for daily structured activities. This intervention helps combat the symptoms by providing a routine and purpose to the client's day, addressing the issues of psychomotor retardation and amotivation. Structured activities can help establish a sense of normalcy, improve motivation, and regulate sleep patterns. Encouraging exercise (Choice A) can be beneficial but may be challenging for a client experiencing psychomotor retardation. Developing a list of pleasurable activities (Choice B) may not address the need for structure and routine in the client's daily life. Providing education on sleep enhancement methods (Choice C) is important but may not be sufficient to address the overall functional impairment in this case.
Which client statement suggests that the client is using a defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit?
- A. At least I hit the wall instead of hitting the psychiatric aide.
- B. I am here because the police thought I was doing something wrong.
- C. I want to be here because I know it is the best psychiatric facility.
- D. Don't believe everything my family tells you, I am not crazy.
Correct Answer: A
Rationale: The correct answer is A because the client is projecting their own aggressive tendencies onto the psychiatric aide by suggesting hitting the wall instead of the aide. This statement reflects projection, a defense mechanism where one attributes their unacceptable feelings or impulses to others. Choice B reflects externalization rather than projection, Choice C reflects rationalization, and Choice D reflects denial.
While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-taking during an interview?
- A. The client's comfort level is increased when the nurse maintains eye contact while taking notes.
- B. The interview process is enhanced with note-taking, allowing the client to speak at a normal pace.
- C. Note-taking during an interview is not a legal obligation of the examining nurse.
- D. The nurse's ability to directly observe the client's nonverbal communication is limited with note-taking.
Correct Answer: D
Rationale: During an interview, note-taking can hinder the nurse's ability to directly observe the client's nonverbal cues such as body language, facial expressions, and tone of voice. These nonverbal cues are crucial for understanding the client's emotions, feelings, and overall communication. Therefore, it is essential for the nurse to strike a balance between note-taking for documentation purposes and actively observing the client's nonverbal communication to ensure a comprehensive assessment. Choices A, B, and C are incorrect because maintaining eye contact, enhancing the interview process with note-taking, and legal obligations of note-taking during an interview do not directly address the issue of limited observation of nonverbal communication while taking notes.
A male client approaches the nurse with an angry expression on his face and raises his voice, saying, "My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!" The nurse recognizes that the client is using which defense mechanism?
- A. Denial
- B. Projection
- C. Rationalization
- D. Splitting
Correct Answer: B
Rationale: The correct answer is B: Projection. In this scenario, the client is projecting his own feelings of anger onto his roommate by attributing his anger to the roommate. Projection involves shifting one's feelings, thoughts, or impulses onto another person. Denial (choice A) is the refusal to accept reality, Rationalization (choice C) involves justifying behaviors with logical reasons, and Splitting (choice D) is the inability to integrate positive and negative qualities of oneself or others.
A male client with schizophrenia is being discharged from the psychiatric unit after being stabilized with antipsychotic medications. What is the most important instruction to include in the discharge teaching?
- A. "You should see your psychiatrist every 6 months."
- B. "It's important to adhere to the medication regimen as prescribed."
- C. "Try to avoid caffeine and alcohol completely."
- D. "You should exercise daily to maintain a healthy lifestyle."
Correct Answer: B
Rationale: The most important instruction to include in the discharge teaching for a male client with schizophrenia who has been stabilized with antipsychotic medications is to adhere to the medication regimen as prescribed. Medication adherence is crucial in managing schizophrenia, preventing relapse, and maintaining stability. While seeing the psychiatrist regularly (Choice A) is important, adherence to medication is more critical for the client's immediate well-being. Avoiding caffeine and alcohol (Choice C) may be beneficial but is not as crucial as medication adherence. Daily exercise (Choice D) is important for overall health but is not the most critical instruction for managing schizophrenia.