Nokea
A client who has agoraphobia (a fear of crowds) is starting desensitization therapy with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?
- A. Encourage the substitution of positive thoughts for negative ones.
- B. Establish trust by providing a calm, safe environment.
- C. Gradually expose the client to larger crowds.
- D. Encourage deep breathing when anxiety escalates in a crowd.
Correct Answer: B
Rationale: Establishing trust by providing a calm and safe environment is crucial for the success of desensitization therapy in clients with agoraphobia. This approach helps the client feel safe and secure, allowing them to gradually confront their fear of crowds. Encouraging positive thoughts (choice A) is beneficial but not as immediately critical as creating a safe space. Progressively exposing the client to larger crowds (choice C) should occur after trust is established and in a controlled manner. Encouraging deep breathing (choice D) is helpful, but creating a safe environment takes precedence to build a foundation for successful desensitization.
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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.
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 admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the RN to ask the client?
- A. Have you lost interest in the activities you once enjoyed?
- B. Is your ability to think or concentrate reduced?
- C. How many consecutive hours do you sleep at night?
- D. Do you hear sounds or voices that others do not hear?
Correct Answer: D
Rationale: In this scenario, the most critical question for the RN to ask the client relates to hallucinations. Hallucinations, such as hearing sounds or voices others do not hear, are a hallmark symptom of schizophrenia. This inquiry is vital for assessing the presence of psychotic symptoms and the potential relapse of the client's condition. Choices A, B, and C, although important in assessing overall mental health, do not directly address the core symptomatology of schizophrenia or the potential impact of discontinuing antipsychotic medication abruptly.
A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client's plan of care should include what priority problem?
- A. Acute confusion.
- B. Ineffective community coping.
- C. Disturbed sensory perception.
- D. Self-care deficit.
Correct Answer: A
Rationale: Acute confusion is the priority problem because it directly impacts the client's safety and functioning. In this scenario, the client is disoriented, disorganized, and confused, which can pose immediate risks to her well-being. Ineffective community coping, disturbed sensory perception, and self-care deficit are not as urgent in this situation. Ineffective community coping focuses on the client's ability to manage stress related to the community, disturbed sensory perception pertains to alterations in sensory input, and self-care deficit involves the inability to perform activities of daily living independently. While these issues may also need addressing, acute confusion takes precedence due to the immediate safety concerns it presents.
Carolina is surprised when her patient does not show for a regularly scheduled appointment. When contacted, the patient states, 'I don't need to come see you anymore. I have found a therapy app on my phone that I love.' How should Carolina respond to this news?
- A. That sounds exciting, would you be willing to visit and show me the app?
- B. At this time, there is no real evidence that the app can replace our therapy.
- C. I am not sure that is a good idea right now; we are so close to progress.
- D. Why would you think that is a better option than meeting with me?
Correct Answer: A
Rationale: Carolina should respond with choice A as it shows interest and willingness to understand the patient's new approach. By asking the patient to show the app, Carolina demonstrates openness to exploring the patient's perspective and the technology they find helpful. Choice B is incorrect as it appears dismissive, failing to acknowledge the patient's autonomy in choosing an alternative therapy method. Choice C is also inappropriate as it undermines the patient's decision-making and progress achieved so far. Choice D comes off as confrontational and judgmental, which could lead to the patient feeling defensive and less likely to engage in a constructive conversation.