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A client with depression remains in bed most of the day, declines activities, and refuses meals. Which nursing problem has the greatest priority for this client?
- A. Loss of interest in diversional activities.
- B. Social isolation.
- C. Refusal to address nutritional needs.
- D. Low self-esteem.
Correct Answer: C
Rationale: The correct answer is C: 'Refusal to address nutritional needs.' In this scenario, the client's refusal to eat and address their nutritional needs poses an immediate threat to their physical health. Without proper nutrition, the client is at risk of malnutrition and its associated complications. While addressing social isolation, low self-esteem, and loss of interest in diversional activities are important aspects of holistic care for a client with depression, ensuring proper nutrition takes precedence due to the critical impact it has on the client's physical well-being. Therefore, the priority is to address the client's refusal to eat and address their nutritional needs to prevent further deterioration of their health.
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A male client with schizophrenia tells the RN that he is being watched and that the television is speaking directly to him. Which response by the RN is appropriate?
- A. "The television cannot speak to you."
- B. "That sounds very frightening for you."
- C. "You should ignore the television."
- D. "Why do you think the television is talking to you?"
Correct Answer: B
Rationale: Option B is the correct response because it acknowledges the client's feelings and demonstrates empathy. By stating that the situation sounds frightening, the RN validates the client's experience without denying or reinforcing the delusion. This approach helps build rapport and trust with the client, which is essential in therapeutic communication. Options A and C are dismissive and may invalidate the client's experience, potentially worsening the trust relationship. Option D is confrontational and may make the client defensive, hindering effective communication and rapport-building.
A female client with a history of major depressive disorder is experiencing a worsening of symptoms. Which statement by the client indicates a potential risk for suicide?
- A. "I've been feeling more tired than usual."
- B. "I've been thinking about how much better everyone would be without me."
- C. "I've been having trouble sleeping lately."
- D. "I feel like I can't handle everything."
Correct Answer: B
Rationale: The client's statement about thinking that everyone would be better off without her indicates suicidal ideation. This statement is a significant warning sign for suicide risk and requires immediate intervention. Choices A, C, and D reflect common symptoms of depression but do not directly indicate suicidal thoughts or intentions. Feeling tired, having trouble sleeping, and feeling overwhelmed are typical symptoms of major depressive disorder but do not necessarily suggest an imminent risk of suicide like the statement in option B does.
What assessment questions should the nurse ask when attempting to determine a teenager's mental health resilience? Select all that apply.
- A. How did you cope when your father deployed with the Army for a year in Iraq?
- B. Who did you go to for advice while your father was away for a year in Iraq?
- C. How do you feel about talking to a mental health counselor?
- D. Where do you see yourself in 10 years?
Correct Answer: C
Rationale: The question 'How do you feel about talking to a mental health counselor?' is the most appropriate to assess the teenager's mental health resilience as it directly addresses their willingness to seek help and cope effectively. Choices A and B focus on coping mechanisms during a specific event, which may not reflect the teenager's overall resilience. Choice D is more related to future aspirations rather than assessing current mental health resilience.
A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the nurse to implement?
- A. Avoid acknowledging the behavior.
- B. Isolate the client from other clients.
- C. Administer a PRN sedative.
- D. Escort the client to his room.
Correct Answer: D
Rationale: The best intervention for a male client with schizophrenia displaying echolalia, which is disruptive to others, is for the nurse to escort the client to his room. Echolalia, the constant repetition of others' words, can be disruptive in a communal setting. By guiding the client to a private space like his room, the nurse helps manage the behavior without isolating or medicating the client unnecessarily. Avoiding acknowledging the behavior (Choice A) does not address the issue, isolating the client (Choice B) may exacerbate feelings of exclusion, and administering a PRN sedative (Choice C) should be reserved for situations where there is imminent risk or severe agitation, not for managing echolalia.
A client with anorexia nervosa has a body mass index (BMI) of 16.5 and has been diagnosed with bradycardia. Which of the following findings should the RN be most concerned about?
- A. Body temperature of 96.8°F.
- B. Heart rate of 52 BPM.
- C. Serum potassium level of 4.1 mEq/L.
- D. Electrocardiogram (ECG) changes.
Correct Answer: D
Rationale: In a client with anorexia nervosa and bradycardia, monitoring for ECG changes is crucial as these changes may indicate potentially life-threatening cardiac complications. While other findings like low body temperature, bradycardia, and serum potassium levels are concerning, ECG changes specifically reflect the impact of bradycardia on the heart's electrical activity and should be the priority for the nurse to assess and address.