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A client with post-traumatic stress disorder (PTSD) reports having frequent nightmares. What is the nurse's best response?
- A. Nightmares are common with PTSD and should decrease over time.
- B. Try to avoid thinking about the trauma before going to bed.
- C. Let's discuss some relaxation techniques you can use before bedtime.
- D. I will ask the healthcare provider to prescribe a sleep aid.
Correct Answer: C
Rationale: The best response for the nurse is to discuss relaxation techniques with the client that can help reduce anxiety and stress before bedtime. This approach may potentially decrease the frequency of nightmares by promoting a more calming and peaceful pre-sleep routine. Choice A is incorrect because while nightmares can be common with PTSD, it is not guaranteed that they will decrease over time. Choice B is incorrect as avoiding thinking about the trauma may not address the underlying issue causing the nightmares. Choice D is incorrect as prescribing a sleep aid should be considered as a last resort after trying non-pharmacological interventions.
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A client with depression reports difficulty sleeping. What is the most appropriate nursing intervention?
- A. Encourage the client to take short naps during the day.
- B. Suggest the client drink a warm beverage before bedtime.
- C. Recommend the client exercise immediately before bedtime.
- D. Advise the client to take a sleep aid nightly.
Correct Answer: B
Rationale: The most appropriate nursing intervention for a client with depression reporting difficulty sleeping is to suggest the client drink a warm beverage before bedtime. A warm beverage can promote relaxation and help establish a bedtime routine, which may aid in improving sleep quality. Encouraging short naps during the day (Choice A) may disrupt the client's nighttime sleep pattern. Recommending exercise immediately before bedtime (Choice C) can have a stimulating effect, making it harder for the client to fall asleep. Advising the client to take a sleep aid nightly (Choice D) should only be considered after other non-pharmacological interventions have been attempted and in consultation with a healthcare provider due to potential side effects and risks associated with sleep aids.
A client with schizophrenia receiving haloperidol (Haldol) has a stiff, mask-like facial expression and difficulty speaking. What is the nurse's priority action?
- A. Administer a PRN dose of lorazepam (Ativan).
- B. Encourage the client to perform facial exercises.
- C. Notify the healthcare provider of possible extrapyramidal symptoms (EPS).
- D. Document the findings and continue to monitor the client.
Correct Answer: C
Rationale: The correct answer is to notify the healthcare provider of possible extrapyramidal symptoms (EPS). The symptoms described, such as a stiff, mask-like facial expression and difficulty speaking, are indicative of EPS, which can be a serious side effect of haloperidol. It is crucial to involve the healthcare provider immediately to address these symptoms. Administering a PRN dose of lorazepam (Choice A) is not the priority in this situation, as it does not address the underlying cause of EPS. Encouraging the client to perform facial exercises (Choice B) is not appropriate and may not effectively manage EPS. Documenting the findings and continuing to monitor the client (Choice D) is important but not the priority when potential EPS is present; immediate action by notifying the healthcare provider is essential.
In the described scenario, a manic client threatens a nurse with physical violence after being told they cannot have a stripper perform. What is the most appropriate action for the LPN/LVN to take?
- A. Orient the client to time, person, and place
- B. Tell the client that the behavior is inappropriate
- C. Escort the manic client to her room, with assistance
- D. Tell the client that smoking privileges are revoked for 24 hours
Correct Answer: C
Rationale: In this situation, where the manic client becomes verbally abusive and threatens physical violence, the most appropriate action for the LPN/LVN is to escort the client to her room with assistance. This action helps ensure the safety of both the client and the nurse, while also providing a controlled environment that can help de-escalate the situation. Choices A and B do not address the immediate safety concerns presented by the client's behavior. Choice D, revoking smoking privileges, is not directly related to the client's current behavior and does not address the threat of violence.
Which diet selection by a client who is depressed and taking the MAO inhibitor tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen?
- A. Hamburger, French fries, and chocolate milkshake.
- B. Liver and onions, broccoli, and decaffeinated coffee.
- C. Pepperoni and cheese pizza, tossed salad, and a soft drink.
- D. Roast beef, baked potato with butter, and iced tea.
Correct Answer: D
Rationale: The correct answer is (D) Roast beef, baked potato with butter, and iced tea. This diet selection indicates that the client understands the dietary restrictions imposed by taking tranylcypromine sulfate (Parnate) because it does not contain tyramine. Tyramine in foods can interact with MAO inhibitors like Parnate, leading to a hypertensive crisis, which is life-threatening. Choices (A, B, and C) contain foods high in tyramine like cheese, pepperoni, and chocolate, which are contraindicated for clients taking MAO inhibitors.
A client with bipolar disorder is being treated with lithium. The nurse should monitor the client for which early sign of lithium toxicity?
- A. Diarrhea
- B. Tremors
- C. Polyuria
- D. Blurred vision
Correct Answer: A
Rationale: Corrected Rationale: Diarrhea is an early sign of lithium toxicity. When a client being treated with lithium presents with diarrhea, it can indicate the beginning of lithium toxicity. Monitoring for this symptom is crucial as it can progress to more severe toxicity if not addressed promptly. Tremors (choice B) are more commonly associated with the therapeutic effects of lithium rather than toxicity. Polyuria (choice C) is a common side effect of lithium, but it is not typically an early sign of toxicity. Blurred vision (choice D) is not a common early sign of lithium toxicity. Therefore, option A is the correct answer.