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A client with an eating disorder tells the RN, 'I've been eating only 400 calories per day and have been taking diuretics to lose weight.' What is the RN's best response?
- A. "Your diet is very harmful and needs to be changed immediately."
- B. "It's important to monitor your calorie intake carefully."
- C. "Have you noticed any physical effects from this low-calorie diet?"
- D. "The diuretics could be causing your body to lose essential nutrients."
Correct Answer: D
Rationale: The correct response is D. By addressing the potential harm of diuretics and the low-calorie diet, the nurse effectively addresses both aspects of the client's disordered eating behavior. Choice A is too direct and does not provide information on the specific issue of diuretics. Choice B focuses solely on monitoring calorie intake without addressing the use of diuretics. Choice C inquires about physical effects but does not address the overall risks associated with diuretics and low-calorie intake.
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While sitting in the day room of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the RN. The two trade places, and the RN demonstrates the client's behaviors. What is the main goal of this therapeutic technique?
- A. Initiate a non-threatening conversation with the client.
- B. Dialog about the ineffectiveness of his interactions.
- C. Allow the client to identify the way he interacts.
- D. Discuss the client's feelings when he responds.
Correct Answer: C
Rationale: The main goal of the therapeutic technique described is to allow the client to identify the way he interacts. This technique helps promote self-awareness in the client by mirroring his behavior back to him, which can lead to insights about his own communication style. Option A is incorrect as the goal is not just to initiate conversation but to facilitate self-reflection. Option B is incorrect because the focus is not on discussing the ineffectiveness of the interactions but on self-awareness. Option D is incorrect as the primary aim is not to discuss the client's feelings but to help him recognize his interaction patterns.
A female client on a psychiatric unit is sweating profusely while vigorously doing push-ups and then running the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, "I am the boss here. I do what I want." Which nursing problem best supports these observations?
- A. Deficient diversional activity related to excess energy level.
- B. Disturbed personal identity related to grandiosity.
- C. Risk for activity intolerance related to hyperactivity.
- D. Risk for other-directed violence related to disruptive behaviors.
Correct Answer: D
Rationale: The client's behavior of engaging in disruptive and aggressive actions, as well as claiming authority over others in the setting, indicates a risk for other-directed violence. This behavior poses a potential threat to the safety of others in the environment. Choice A is incorrect as the client's behavior is not solely indicative of a lack of diversional activities but rather a more serious issue. Choice B is incorrect as the behavior described does not primarily reflect disturbances in personal identity but rather displays of power and aggression. Choice C is incorrect as the client's actions do not suggest an intolerance to activity but rather an excessive and potentially harmful level of hyperactivity.
A client with a diagnosis of schizophrenia is exhibiting negative symptoms such as anhedonia and social withdrawal. Which intervention should be a priority for the nurse?
- A. Encourage participation in group activities.
- B. Administer prescribed antipsychotic medication.
- C. Assist the client in setting realistic goals.
- D. Promote engagement in social interactions.
Correct Answer: A
Rationale: Encouraging participation in group activities is a priority intervention for a client with schizophrenia exhibiting negative symptoms like anhedonia and social withdrawal. Group activities provide structured social interactions and can help the client gradually re-engage with others, potentially reducing social withdrawal and improving social skills. Administering antipsychotic medication (Choice B) is essential in managing positive symptoms of schizophrenia such as hallucinations and delusions, not negative symptoms like anhedonia and social withdrawal. While assisting the client in setting realistic goals (Choice C) is important for overall care, addressing social withdrawal and anhedonia is more immediate. Promoting engagement in social interactions (Choice D) is beneficial, but encouraging participation in group activities provides a structured and supportive environment that can specifically target the negative symptoms being exhibited.
The nurse accepts a transfer to the mental health unit and understands that the client is distractible and is exhibiting a decreased ability to concentrate. The nurse has only 15 minutes to talk with the client. To develop a treatment plan for this client, which assessment is most important for the nurse to obtain?
- A. Motivation for treatment
- B. History of substance use
- C. Medication compliance
- D. Mental status examination
Correct Answer: D
Rationale: A mental status examination is the most important assessment for the nurse to obtain in this scenario. It provides a comprehensive view of the client's current cognitive functioning, including their level of alertness, orientation, memory, attention, and thought process. Understanding the client's mental status is crucial for developing an appropriate treatment plan. The other options, such as motivation for treatment, history of substance use, and medication compliance, are important aspects to consider but may not directly address the client's current cognitive state and immediate treatment needs as effectively as a mental status examination.
A male adolescent was admitted to the unit two days ago for depression. When the mental health nurse tries to interview the client to establish rapport, he becomes very irritated and sarcastic. Which action is best for the nurse to take?
- A. Offer to play a game of cards with the client.
- B. Report the behavior to the next shift.
- C. Document the behavior in the chart.
- D. Plan to talk with the client the next day.
Correct Answer: A
Rationale: Offering to play a game of cards with the adolescent is the best action for the nurse to take in this situation. Engaging in an activity like playing a game can help establish rapport with the adolescent as it provides a more relaxed and non-threatening environment for communication. This approach can help the adolescent feel more comfortable and open up, as adolescents often find it easier to communicate when involved in an activity. Reporting the behavior to the next shift, documenting the behavior, or planning to talk with the client the next day do not directly address the immediate need to establish rapport and improve communication with the adolescent.