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A client with Alzheimer's disease is becoming increasingly agitated and combative in the late afternoon. What is the most appropriate intervention?
- A. Offer a sedative medication to calm the client.
- B. Encourage the client to rest in a quiet, low-stimulation environment.
- C. Use reality orientation to reduce confusion.
- D. Engage the client in physical activity to reduce agitation.
Correct Answer: B
Rationale: Encouraging the client to rest in a quiet, low-stimulation environment is the most appropriate intervention for a client with Alzheimer's disease who is becoming agitated and combative in the late afternoon. This approach helps reduce agitation and prevent overstimulation, providing a calming and soothing environment for the client. Offering a sedative medication (Choice A) should be avoided as it may have side effects and should only be considered as a last resort. Reality orientation (Choice C) may increase confusion and distress in clients with advanced Alzheimer's disease. Engaging the client in physical activity (Choice D) could potentially escalate the agitation rather than reduce it in this scenario.
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The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours after the client's admission to the unit?
- A. Monitor appetite and observe intake during meals.
- B. Maintain safety in the client's environment.
- C. Provide ongoing, supportive contact.
- D. Encourage participation in activities.
Correct Answer: B
Rationale: The most critical intervention to implement during the first 48 hours after admitting a depressed client is to maintain safety (B). Depression increases the risk of suicide; hence ensuring a safe environment is the priority. While monitoring appetite (A), providing supportive contact (C), and encouraging participation in activities (D) are important aspects of care for a depressed client, ensuring safety takes precedence in the initial phase of admission.
A 20-year-old female client with schizophrenia is scheduled to receive risperidone (Risperdal) 2mg at bedtime. When the nurse attempts to administer the medication, the client states, 'I am not going to take that medicine, and you can't make me.' What action should the nurse take?
- A. Administer the medication via a nasogastric tube.
- B. Substitute an injectable form of the medication.
- C. Encourage the client to take the medicine because it will help her sleep.
- D. Document in the client's record that the medication was refused.
Correct Answer: D
Rationale: In this scenario, the correct action for the nurse to take is to respect the client's autonomy and decision-making capacity. It's crucial to document the medication refusal accurately in the client's record. Administering the medication via a nasogastric tube or substituting it with an injectable form would violate the client's right to refuse treatment and should only be considered in extreme cases after consulting with the healthcare team. Encouraging the client to take the medication because it will help her sleep disregards her autonomy and choice in the matter.
A nurse working in a psychiatric unit is assessing a client who appears to be responding to internal stimuli. The client is laughing and talking to himself. What is the nurse's best initial response?
- A. Approach the client and ask if he is hearing voices.
- B. Ignore the behavior as it is common in psychiatric settings.
- C. Encourage the client to express his thoughts verbally.
- D. Observe the client's behavior from a distance.
Correct Answer: A
Rationale: Approaching the client and asking if he is hearing voices is the best initial response by the nurse. This action can help assess the situation and determine if the client is experiencing hallucinations that may require immediate intervention. Choice B is incorrect because ignoring the behavior could lead to missing important signs of distress or potential risks. Choice C may not address the immediate concern of assessing for hallucinations. Choice D is also not ideal as observing from a distance may not provide the necessary information for immediate assessment and intervention.
A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates her mannerisms. Which defense mechanism does the nurse recognize in this client?
- A. Sublimation.
- B. Identification.
- C. Introjection.
- D. Repression.
Correct Answer: B
Rationale: Identification is the correct answer. It is a defense mechanism where an individual unconsciously models themselves after someone they admire or feel close to. In this scenario, the client is imitating the nurse's mannerisms, indicating identification. Sublimation involves channeling unacceptable impulses into socially acceptable activities. Introjection is the internalization of external attitudes or voices, while repression involves suppressing unwanted thoughts or desires.
A 65-year-old female client complains to the nurse that recently she has been hearing voices. What question should the nurse ask this client first?
- A. Do you have problems with hallucinations?
- B. Are you ever alone when you hear the voices?
- C. Has anyone in your family had hearing problems?
- D. Do you see things that others cannot see?
Correct Answer: B
Rationale: The nurse should first ask if the client is ever alone when she hears the voices. This question helps differentiate between potential auditory hallucinations and other causes like hearing loss. Choice A is not the best first question as it assumes the client is experiencing hallucinations without exploring other possibilities. Choice C is irrelevant to the immediate concern of hearing voices. Choice D pertains to visual hallucinations which are not described in the client's complaint of hearing voices.