Nokea
A client who has agoraphobia is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?
- A. Establish trust by providing a calm, safe environment
- B. Encourage deep breathing when anxiety escalates in a crowd
- C. Progressively expose the client to larger crowds
- D. Encourage substitution of positive thoughts for negative ones
Correct Answer: A
Rationale: Establishing trust through a calm, safe environment is foundational for effective desensitization in agoraphobia, supporting the client's sense of security. Deep breathing and positive thoughts are secondary. Progressive exposure comes after trust is established.
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During the admission assessment to the mental health unit, a client reports that the people at the office, where the client works, are antagonistic and the client is thinking of shooting the supervisor. The client asks the nurse not to reveal this to anyone else. The nurse immediately notifies the client's therapist and other team members of the client's thoughts. The therapist then calls the client's supervisor and shares the client's thoughts about shooting the supervisor. Which outcome is best based on the action of the nurse?
- A. The nurse is reprimanded for divulging confidential patient information without obtaining informed consent
- B. Both the nurse and therapist are reprimanded for divulging confidential patient information to others
- C. The nurse and therapist will be asked to educate other team members on appropriate sharing of client information
- D. The therapist is reprimanded for divulging confidential patient information without obtaining consent
Correct Answer: C
Rationale: The nurse appropriately shared the threat with the team to ensure safety, but the therapist's disclosure to the supervisor may breach confidentiality. Educating team members on appropriate information sharing balances safety and privacy. Reprimands are less constructive unless clear violations occurred.
The nurse has received a new prescription for the client to begin taking sertraline. Prior to administering the initial dose of sertraline, it is most important for the nurse to obtain which information?
- A. Any history of heart disease
- B. Familial history of mental illness
- C. Medication history
- D. Current weight
Correct Answer: C
Rationale: Obtaining a thorough medication history is essential to identify potential drug interactions, allergies, or contraindications for sertraline. Heart disease history is relevant but less critical. Familial mental illness history is not immediately necessary. Weight does not typically affect sertraline dosing.
An adult female client is brought to the Emergency Center after fainting at work. The nurse completes an assessment of the client and identifies caregiver role strain as a nursing problem. Which information best supports this problem?
- A. Cares for an older parent and her children
- B. Anxious to leave for personal appointments
- C. Takes naps in her car during lunch hour
- D. Works an average of 60 hours per week
Correct Answer: A
Rationale: Caring for an older parent and children simultaneously indicates significant caregiver role strain due to increased responsibilities. Anxiety, napping, and long work hours suggest stress but are less specific to caregiving demands.
In conducting the initial assessment of a preoperative client, the nurse notes that the client's home medications include the monoamine oxidase (MAO) inhibitor phenelzine. Because of this client's medication history, which assessment finding is most important for the nurse to monitor?
- A. Blood pressure
- B. Urinary output
- C. Respiratory rate
- D. Temperature
Correct Answer: A
Rationale: MAO inhibitors like phenelzine can cause hypertensive crises, especially with certain foods or medications. Monitoring blood pressure is critical to detect this life-threatening complication. Urinary output, respiratory rate, and temperature are less directly affected by MAO inhibitors.
A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?
- A. Current vital signs
- B. White blood cell count
- C. 24-hour urinary output
- D. Blood sugar level
Correct Answer: A
Rationale: Current vital signs are critical for assessing NMS, a life-threatening side effect of haloperidol, indicated by fever, unstable blood pressure, and tachycardia. White blood cell count, urinary output, and blood sugar are less specific to NMS.