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A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take first?
- A. Implement the client's behavioral modification plan.
- B. Document the size and location of the cuts.
- C. Assess the client's intent and suicide risk.
- D. Administer a tetanus antitoxin.
Correct Answer: C
Rationale: The correct answer is C: Assess the client's intent and suicide risk. This is the first action the nurse should take to ensure the immediate safety of the client. By assessing the client's intent and suicide risk, the nurse can determine the severity of the situation and the appropriate level of intervention needed. This assessment will guide the nurse in developing a safety plan to prevent further self-harm or potential suicide attempts.
Choice A is incorrect because implementing the client's behavioral modification plan is not the priority when the client is actively engaging in self-harm behavior.
Choice B is incorrect as documenting the size and location of the cuts can be done after ensuring the client's immediate safety.
Choice D is incorrect as administering a tetanus antitoxin is not the priority in this situation and does not address the client's emotional and psychological needs.
In summary, assessing the client's intent and suicide risk is the most critical step to ensure the client's safety and well-being in a situation involving self-h
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A nurse is caring for a client who professes a deep and everlasting love for his girlfriend one day and the next day refuses to speak to her or allow her to visit. The nurse recognizes this client behavior as which of the following defense mechanisms?
- A. Repression
- B. Splitting
- C. Sublimation
- D. Undoing
Correct Answer: B
Rationale: Splitting is characterized by viewing things as all good or all bad, commonly seen in personality disorders.
A nurse in the emergency department is implementing a plan of care for an older adult client who is experiencing delirium tremens. Which of the following actions should the nurse take first?
- A. Administer diazepam.
- B. Raise the side rails of the bed.
- C. Obtain a medical history.
- D. Start intravenous fluids.
Correct Answer: A
Rationale: The correct answer is A: Administer diazepam. Delirium tremens is associated with severe alcohol withdrawal and can be life-threatening. Diazepam is a benzodiazepine used to manage alcohol withdrawal symptoms by reducing agitation and preventing seizures. Administering diazepam first is crucial to stabilize the client's condition and prevent complications. Raising the side rails of the bed (B) can be important for safety but does not address the immediate medical need. Obtaining a medical history (C) is important for understanding the client's background but is not the priority in this acute situation. Starting intravenous fluids (D) may be necessary to address dehydration, but managing the withdrawal symptoms with diazepam takes precedence.
A nurse is caring for a client who is to start chemotherapy for advanced breast cancer. She tells the nurse she is worried about the adverse effects of the treatment. Which of the following responses should the nurse make?
- A. "I will have your provider discuss the adverse effects with you before the treatment begins."
- B. "Someone from the American Cancer Society will be here soon to answer your questions."
- C. "What is it about the adverse effects that concern you?"
- D. "I agree. Sometimes the adverse effects can be worse than the disease."
Correct Answer: C
Rationale: Correct Answer: C
Rationale: The nurse should respond with "What is it about the adverse effects that concern you?" This response shows empathy, encourages open communication, and allows the nurse to address the client's specific fears or concerns. It also promotes a patient-centered approach to care, enhancing trust and rapport between the nurse and the client. This response demonstrates active listening and provides an opportunity for individualized education and support.
Incorrect Answers:
A: This response defers the responsibility to the provider and does not address the client's concerns directly.
B: This response does not address the client's specific concerns and may not provide the necessary support.
D: This response dismisses the client's concerns and does not address the root of her worries, potentially increasing anxiety.
E, F, G: No information provided.
A nurse is assessing a client who has a diagnosis of conversion disorder. Which of the following is an expected finding?
- A. Frequent manic episodes.
- B. Refusal of medication due to paranoia.
- C. Preoccupation with manifestations of various illnesses.
- D. Involuntary loss of a sensory function.
Correct Answer: D
Rationale: The correct answer is D: Involuntary loss of a sensory function. In conversion disorder, physical symptoms are present without a known medical cause. This can manifest as sensory deficits such as blindness or paralysis. This finding is expected as it is a hallmark of conversion disorder. Manic episodes (A) are more indicative of bipolar disorder, medication refusal due to paranoia (B) may be seen in conditions like schizophrenia, and preoccupation with various illnesses (C) is characteristic of somatic symptom disorder. Therefore, the correct choice is D as it aligns with the presentation of conversion disorder.
A nurse is caring for a client who has schizophrenia and tells the nurse, "They lie about me all the time, and they are trying to poison my food." Which of the following statements should the nurse make?
- A. "You are mistaken. Nobody is lying about you or trying to poison you."
- B. "You seem to be having very frightening thoughts."
- C. "Why do you think you are being lied about and poisoned?"
- D. "Who is lying about you and trying to poison you?"
Correct Answer: B
Rationale: The correct answer is B: "You seem to be having very frightening thoughts." This response acknowledges the client's feelings without denying or confirming the delusions. It shows empathy and validates the client's experience without reinforcing the delusions. Option A is incorrect as it denies the client's beliefs, which can lead to distrust. Option C may encourage the client to provide more details about the delusions. Option D may inadvertently validate the delusions by asking for specific details.