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A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client's rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?
- A. Disrupts group activities.
- B. Wanders into client's rooms.
- C. Talks with nonsensical words.
- D. Refuses antipsychotic medications.
Correct Answer: B
Rationale: Wandering into client's rooms poses a safety risk to both the client and others, indicating a need for constant observation to prevent potential harm.
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A client with post-traumatic stress disorder (PTSD) is experiencing a dissociative disorder episode. The situation quickly escalates, and the client becomes physically aggressive. Which intervention should the nurse implement first?
- A. Request a team member to assist with seclusion and restraint.
- B. Administer lorazepam 1.5 mg intramuscularly twice daily as needed.
- C. Confirm the client's identity and orientation to time and place.
- D. Inspect the area for objects that can be used in a dangerous manner.
- E. None.
- F. None.
Correct Answer: D
Rationale: Inspecting the area for dangerous objects is the first priority to ensure safety during the client's aggressive behavior.
A client who is experiencing a severe level of anxiety reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?
- A. Help the client identify thoughts that may be triggers.
- B. Explore past behaviors that have provided relief.
- C. Attempt to distract to another focus or activity.
- D. Speak calmly to the client stating assurance of safety.
Correct Answer: D
Rationale: Speaking calmly and providing assurance of safety is the first step in managing severe anxiety, helping to stabilize the client.
The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?
- A. Participates in individual and group therapy.
- B. Demonstrates effective ways to cope with anxiety.
- C. Takes all antianxiety medications as prescribed.
- D. Learns methods of relaxation to reduce anxiety.
Correct Answer: B
Rationale: Demonstrating effective ways to cope with anxiety is the most important outcome to address the client's self-harming behavior and promote healthier coping mechanisms.
A client diagnosed with schizophrenia has been receiving haloperidol for the past year, and the treatment plan includes moving the client to a lower maintenance dosage. Which intervention should the nurse include in this client's plan of care? (Select all that apply)
- A. Shielding the client from direct sunlight when outdoors.
- B. Gradually withdrawing the medication over several days.
- C. Enforcing a fluid restriction during dosage adjustment.
- D. Increasing the dosage if the white blood cell count drops.
Correct Answer: A,B
Rationale: Shielding from sunlight prevents sunburn due to haloperidol's photosensitivity, and gradual withdrawal avoids symptom worsening.
A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit's day room. Which action should the nurse implement first?
- A. Sit in the chair next to the client.
- B. Listen to what the client is saying.
- C. Escort the client to his room.
- D. Administer a PRN sedative.
Correct Answer: B
Rationale: Listening to what the client is saying is crucial to understand the content and nature of the auditory hallucinations, guiding further interventions.