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A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the nurse implement first?
- A. Show the client the unit.
- B. Explain the nurse's role to the client.
- C. Read the client his/her rights.
- D. Offer medication to the client.
Correct Answer: B
Rationale: Explaining the nurse's role helps establish trust and provides the client with information about who is present and their purpose, facilitating initial communication.
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A male client arrives at the mental health clinic and asks the nurse for more lithium and the antidepressant amitriptyline that he uses to help him sleep. After reviewing the assessment findings with the healthcare provider, a serum creatinine is obtained. Which information supports the reason for this laboratory test?
- A. Creatinine can measure how the body is metabolizing the lithium in the liver.
- B. The effects of amitriptyline can promote and potentiate the risk of lithium toxicity.
- C. The combination of lithium and amitriptyline may need to be changed if creatinine is high.
- D. Lithium is excreted by the kidneys, and creatinine is related to kidney functioning.
Correct Answer: D
Rationale: Lithium is excreted by the kidneys, and monitoring creatinine levels assesses renal function, guiding dosage to prevent toxicity.
A client at the mental health center reports difficulty concentrating at work, feeling very tired during the day, and sleeping 4 to 5 hours at night. To further assess for depression, which question is most important for the nurse to ask?
- A. Have you experienced recent stresses?
- B. What foods do you like to eat?
- C. Do you often feel sad?
- D. Have you experienced sleep changes?
Correct Answer: C
Rationale: Inquiring whether the client often feels sad directly addresses the emotional component of depression, critical for a comprehensive assessment.
A female client with obsessive-compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the nurse at bedtime. What action should the nurse implement?
- A. Explain to the client that her behavior invades the rights of the nursing staff.
- B. Teach the client strategies to control her obsessive-compulsive behavior.
- C. Ask the client to explain why she is keeping a detailed record of her nursing care.
- D. Encourage the client to express her feelings regarding the upcoming procedure.
Correct Answer: D
Rationale: Encouraging the client to express feelings regarding the upcoming procedure addresses potential anxiety driving the behavior, offering a therapeutic approach.
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.