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A client with paranoid schizophrenia has said she feels like throwing a chair. The nurse in the dayroom hears this and wishes to encourage verbalization as a desecalation technique. Which response by the nurse would fulfill this plan?
- A. Tell me what's going on.'
- B. If you throw something, you will be restrained.'
- C. Why are you so upset?'
- D. It's time for group therapy. You can talk there.'
Correct Answer: A
Rationale: The correct answer is A because it encourages the client to express their feelings verbally, promoting communication and potentially preventing escalation of behavior. By saying "Tell me what's going on," the nurse acknowledges the client's emotions and creates a safe space for them to talk. Option B threatens restraint, likely increasing tension. Option C may come off as confrontational. Option D distracts from the immediate need for the client to process their feelings.
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A client is admitted to a day hospital following an episode in which he purchased a gun to use while standing guard over his property to prevent a neighbor from erecting a boundary fence. His wife describes him as distrustful of the motives of others and often interpreting others' motives as threats. She mentions that one time he accused her of having an affair with a neighbor with whom she chatted occasionally. The care plan will list the priority outcome as 'Client will:
- A. admit his action was excessive based on the circumstance.'
- B. write the neighbor a letter of apology.'
- C. demonstrate trust in the nurse.'
- D. identify positive role models.'
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct:
1. Building trust is essential in therapeutic relationships.
2. The client's distrustful nature and misinterpretation of others' motives indicate a lack of trust.
3. By demonstrating trust in the nurse, the client can begin to address his issues with mistrust.
4. Trust in the nurse can lead to better communication and engagement in therapy.
5. Trust in the nurse is foundational for therapeutic progress and successful outcomes.
Summary of why other choices are incorrect:
- Choice A: Admitting his action was excessive is important but does not address the underlying issue of trust.
- Choice B: Writing a letter of apology to the neighbor does not directly address the client's trust issues.
- Choice D: Identifying positive role models may be helpful, but building trust with the nurse is more immediate and directly related to the client's current issues.
An elderly woman is brought to the clinic by her daughter. The client states that she has had a cold for several days. Her daughter states that her mother has been confused about when her routine medications are to be taken and that her mother has never experienced confusion before. Based on this information, it is important that the nurse ask the client whether:
- A. There is a history of mental illness in the family.
- B. She has been given a diagnosis of a mental health disorder in the past.
- C. She can recall her last visit to a physician.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: There is a history of mental illness in the family. This is important because the sudden onset of confusion in an elderly person could be indicative of a new mental health issue or cognitive decline. Asking about a family history of mental illness can provide valuable insights into potential genetic predispositions or underlying conditions that may be contributing to the client's confusion.
Choices B and C are incorrect because the client's own history of mental health diagnosis or ability to recall a physician visit are not directly related to the sudden onset of confusion. Choice D is incorrect because asking about a family history of mental illness could provide crucial information in understanding the client's current condition.
The nurse is assessing a patient with anorexia nervosa. What is the most important physical examination finding to monitor?
- A. Blood pressure and heart rate.
- B. Height and weight changes.
- C. Skin turgor and hydration status.
- D. Respiratory rate and lung function.
Correct Answer: B
Rationale: The correct answer is B: Height and weight changes. In anorexia nervosa, monitoring height and weight changes is crucial as it reflects the patient's nutritional status and overall health. Weight loss and changes in height can indicate severe malnutrition and potential complications. Blood pressure and heart rate (choice A) can be affected by various factors in anorexia nervosa but may not directly reflect the patient's nutritional status. Skin turgor and hydration status (choice C) are important indicators of hydration levels but may not provide a comprehensive assessment of the patient's nutritional status. Respiratory rate and lung function (choice D) are important, but they may not be the most critical physical examination findings to monitor in anorexia nervosa.
A patient has not come out of her room for breakfast. The nurse finds the patient moving restlessly about her room in a disorganized manner. The patient is talking to herself, and her verbal responses to the nurse are nonsensical and suggest disorientation. The nurse notices that the patient's skin is hot and dry, and her pupils are somewhat dilated. All these symptoms are significant departures from the patient's recent presentation. The patient is likely experiencing _____, and the nurse should _____.
- A. anticholinergic toxicity"¦check vital signs and prepare to use a cooling blanket stat
- B. relapse of her psychosis"¦administer PRN antipsychotic drugs and notify her physician
- C. neuroleptic malignant syndrome"¦contact her physician for a transfer to intensive care
- D. agranulocytosis"¦hold her antipsychotic and draw blood for a complete blood count
Correct Answer: A
Rationale: The correct answer is A: anticholinergic toxicity. The patient is displaying symptoms such as restlessness, disorganized behavior, nonsensical verbal responses, disorientation, hot and dry skin, and dilated pupils, which are indicative of anticholinergic toxicity.
Step-by-step rationale:
1. Restlessness and disorganized behavior are common symptoms of anticholinergic toxicity.
2. Nonsensical verbal responses and disorientation are also typical signs of anticholinergic toxicity.
3. Hot and dry skin can be caused by decreased sweating due to anticholinergic effects.
4. Dilated pupils are a classic sign of anticholinergic toxicity.
5. Checking vital signs and preparing to use a cooling blanket is the appropriate immediate action to manage anticholinergic toxicity.
Summary of other choices:
- B: Relapse of psychosis does not explain the physical symptoms like dilated pupils and hot/dry skin.
- C: Neuroleptic malignant syndrome presents with
An elderly client who lives with her daughter and son-in-law and their three children reveals that her daughter sometimes slaps her when she does not move fast enough or spills things. The daughter is a mid-level business executive who is under considerable stress at work. The children are often left in the care of the elderly client. The husband is often out of town on business trips. The daughter states, 'I have so much to do that I become frustrated when my mother can't move fast enough or causes me extra work.' The nurse caring for the mother could appropriately suggest:
- A. Family therapy.
- B. Individual counseling for the daughter.
- C. Respite care for the elderly client.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Family therapy. Family therapy is the most appropriate suggestion because it addresses the dysfunctional dynamics within the family and provides an opportunity for all family members to work through their issues. In this scenario, the daughter's stress at work and lack of coping skills are contributing to the abuse of the elderly client. Family therapy can help the family communicate effectively, set boundaries, and address underlying issues causing the abuse.
Choice B (Individual counseling for the daughter) may help the daughter address her stress and coping mechanisms, but it does not address the family dynamics that are contributing to the abuse. Choice C (Respite care for the elderly client) provides temporary relief but does not address the root cause of the issue. Choice D (None of the above) is incorrect as family therapy is the most appropriate intervention in this case.