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A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the deceased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time?
- A. Not sleeping for several days.
- B. Wishing to be with spouse.
- C. Lack of interest in usual activities.
- D. Eating very little.
Correct Answer: A
Rationale: The correct answer is A: Not sleeping for several days. This is the most important client statement to explore because it indicates the client may be experiencing severe sleep disturbances, which can have a significant impact on their mental and physical health. Lack of sleep can exacerbate symptoms of depression and increase the risk of self-harm or suicide. Therefore, the RN should prioritize exploring this issue to assess the client's safety and provide appropriate interventions.
Choices B, C, and D are also important concerns related to grief and depression, but the immediate risk associated with severe sleep deprivation makes option A the most critical to address first. It is essential to address all client statements eventually, but the urgency of the client's sleep disturbances requires immediate attention.
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A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment, the client tells the RN that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the RN to provide?
- A. Unless your sister has a medical education, ignore her comments.
- B. I can hear that your sister comments are over-whelming you.
- C. Do you think it’s possible that you might be a hypochondriac?
- D. Besides your sister’s comments, what in your life is troubling you?
Correct Answer: B
Rationale: The correct answer is B: "I can hear that your sister's comments are overwhelming you." This response acknowledges the client's feelings and shows empathy, validating her experience. It demonstrates active listening and understanding without judgment. Choice A dismisses the client's feelings, which can be harmful. Choice C may come off as accusatory and may make the client defensive. Choice D shifts the focus away from the client's emotions, missing an opportunity for therapeutic communication.
An RN is providing education to the family of a client diagnosed with schizophrenia who is being treated with clozapine (Clozaril). The RN should instruct the family to report which symptom immediately?
- A. Sore throat
- B. Weight loss
- C. Constipation
- D. Lightheadedness
Correct Answer: A
Rationale: The correct answer is A: Sore throat. Clozapine can cause agranulocytosis, a potentially life-threatening condition characterized by a decrease in white blood cells. Sore throat could indicate an infection, necessitating immediate medical attention to monitor for agranulocytosis. Weight loss (B) and constipation (C) are common side effects of clozapine but do not require immediate reporting. Lightheadedness (D) may be a side effect but not as urgent as a sore throat in this case.
What principle about nurse-patient communication should guide a nurse’s fear about “saying the wrong thing†to a patient?
- A. Patients tend to appreciate a well-meaning person who conveys genuine acceptance, respect, and concern for their situation.
- B. The patient is more interested in talking to you than listening to what you have to say and so is not likely to be offended.
- C. Considering the patient’s history, there is little chance that the comment will do any actual harm.
- D. Most people with a mentally illness have by necessity developed a high tolerance of forgiveness.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Effective nurse-patient communication is based on building trust, empathy, and understanding. Patients value sincerity, respect, and genuine concern from their healthcare providers. By conveying acceptance and respect, nurses can establish a positive rapport with patients, which is essential for effective communication. Patients are more likely to open up and trust a nurse who demonstrates empathy and understanding. This approach helps create a supportive environment for the patient to express their concerns and feel heard. Choices B, C, and D do not address the fundamental principles of building a therapeutic nurse-patient relationship through effective communication. Choice B assumes the patient is not likely to be offended, which may not always be the case. Choice C focuses on potential harm, which is not the primary concern in effective communication. Choice D makes a generalization about individuals with mental illness, which is not relevant to the principle of communication in nursing.
Gilbert, age 19, is described by his parents as a 'moody child' with an onset of odd behavior about at age 14, which caused Gilbert to suffer academically and socially. Gilbert has lost the ability to complete household chores, is reluctant to leave the house, and is obsessed with the locks on the windows and doors. Due to Gilbert’s early and slow onset of what is now recognized as schizophrenia, his prognosis is considered:
- A. Favorable with medication
- B. In the relapse stage
- C. Improvable with psychosocial interventions
- D. To have a less positive outcome
Correct Answer: D
Rationale: The correct answer is D: To have a less positive outcome. Gilbert's symptoms of odd behavior, academic decline, social withdrawal, inability to perform household chores, and obsession with locks are indicative of schizophrenia, a severe and chronic mental disorder. Onset at a young age and slow progression are associated with a poorer prognosis. Medication can help manage symptoms but may not completely alleviate them. Psychosocial interventions may offer some support but are unlikely to significantly alter the course of the illness. The relapse stage implies some improvement followed by worsening, which is not described in Gilbert's case. Therefore, option D is the most appropriate as it reflects the challenging nature of schizophrenia in young individuals like Gilbert.
Pablo is a homeless adult who has no family connection. Pablo passed out on the street and emergency medical services took him to the hospital where he expresses a wish to die. The physician recognizes evidence of substance use problems and mental health issues and recommends inpatient treatment for Pablo. What is the rationale for this treatment choice? Select all that apply.
- A. Intermittent supervision is available in inpatient settings.
- B. He requires stabilization of multiple symptoms.
- C. He has nutritional and self-care needs.
- D. Medication adherence will be mandated.
Correct Answer: A
Rationale: The correct answer is A: Intermittent supervision is available in inpatient settings. In an inpatient treatment setting, Pablo can receive continuous monitoring and supervision, ensuring his safety and well-being. This is crucial for someone like Pablo who is homeless, has substance use issues, and expressed a wish to die. Inpatient treatment can provide a controlled environment where his physical and mental health can be closely monitored, and immediate interventions can be implemented if needed.
Incorrect choices:
B: While stabilization of multiple symptoms is important, the key factor here is the need for constant supervision, which is better provided in an inpatient setting.
C: Although nutritional and self-care needs are important, the primary concern in this case is Pablo's mental health and safety, which can be better addressed in an inpatient setting.
D: While medication adherence is important, it is not the primary reason for recommending inpatient treatment for Pablo. The need for supervision and monitoring takes precedence.