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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 client with obsessive-compulsive disorder (OCD) repeatedly checks to see if the door is locked and asks for reassurance that it is locked. What is the most appropriate intervention by the RN to address this behavior?
- A. Set a specific limit on the number of times the client can check the door.
- B. Help the client find an alternative activity to perform.
- C. Provide consistent reassurance that the door is locked.
- D. Ignore the checking behavior and focus on other behaviors.
Correct Answer: A
Rationale: The correct answer is A: Set a specific limit on the number of times the client can check the door. This intervention helps establish boundaries and structure for the client, which can assist in reducing compulsive behaviors. By setting a specific limit, the client is encouraged to gradually decrease the checking behavior and learn to cope with the anxiety associated with uncertainty. This approach promotes independence and empowerment for the client.
Choice B is incorrect because finding an alternative activity does not directly address the obsessive checking behavior. Choice C is incorrect as providing consistent reassurance reinforces the compulsive behavior. Choice D is incorrect because ignoring the behavior does not actively address or help decrease the compulsive checking.
What assessment question will provide the nurse with information regarding the effects of a woman’s circadian rhythms on her quality of life?
- A. I notice that you frowned and avoided eye contact just now. Don’t you feel well?
- B. Does your heart ever seem to skip a beat?
- C. When was the last time you had a fever?
- D. Do you have problems urinating?
- E. How much sleep do you usually get each night?
Correct Answer: E
Rationale: The correct answer is E: How much sleep do you usually get each night? This question directly addresses the effects of circadian rhythms on the woman's quality of life as sleep patterns are regulated by these rhythms. By understanding her typical sleep duration, the nurse can assess if her circadian rhythms are impacting her quality of life. Choices A, B, C, and D do not specifically address circadian rhythms and their effects. A focuses on general well-being, B on cardiac issues, C on fever, and D on urinary problems. These options do not provide relevant information about circadian rhythms and their impact on quality of life, making them incorrect in this context.
Child protective services have removed 10-year-old Christopher from his parents’ home due to neglect. Christopher reveals to the nurse that he considers the woman next door his 'nice' mom, that he loves school, and gets above average grades. The strongest explanation of this response is:
- A. Temperament
- B. Genetic factors
- C. Resilience
- D. Paradoxical effects of neglect
Correct Answer: C
Rationale: The correct answer is C: Resilience. This is because Christopher's ability to form a positive relationship with the woman next door, his love for school, and above-average grades despite experiencing neglect indicate his resilience. Resilience refers to the capacity to adapt positively in the face of adversity. Christopher's behavior shows his ability to thrive despite challenging circumstances, emphasizing his resilience. Choices A, B, and D do not fully capture Christopher's ability to overcome adversity. Temperament (A) refers to inherent personality traits, genetic factors (B) focus on biological influences, and paradoxical effects of neglect (D) do not directly address Christopher's ability to cope and thrive.
Which nursing statement is an example of reflection?
- A. I think this feeling will pass.
- B. So you are saying that life has no meaning.
- C. I’m not sure I understand what you mean.
- D. You look sad.
Correct Answer: B
Rationale: The correct answer is B because it demonstrates reflective listening by paraphrasing and summarizing the patient's statement. This shows active listening and understanding of the patient's perspective. Choice A is about personal feelings, not reflecting the patient's emotions. Choice C is a statement of uncertainty, not reflective listening. Choice D is an observation, not reflection.
To provide effective care for the patient diagnosed with schizophrenia, the nurse should frequently assess for which associated condition? Select all that apply.
- A. Alcohol use disorder
- B. Major depressive disorder
- C. Stomach cancer
- D. Polydipsia
Correct Answer: A
Rationale: The correct answer is A: Alcohol use disorder. Patients with schizophrenia are at higher risk for co-occurring substance use disorders, including alcohol use disorder. Assessing for alcohol use is crucial as it can worsen symptoms and interfere with treatment. Major depressive disorder (B) is a common comorbidity but is not specific to schizophrenia. Stomach cancer (C) is not directly associated with schizophrenia. Polydipsia (D), excessive thirst, can be seen in schizophrenia due to medication side effects but is not a primary associated condition.