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A client with schizophrenia is experiencing auditory hallucinations. Which intervention should the nurse implement first?
- A. Ask the client to describe the content of the hallucinations.
- B. Instruct the client to ignore the hallucinations.
- C. Administer prescribed antipsychotic medication.
- D. Engage the client in reality-based activities.
Correct Answer: A
Rationale: The initial intervention for a client experiencing auditory hallucinations, especially in schizophrenia, is to assess the content of the hallucinations. By asking the client to describe the hallucinations, the nurse can determine if they are command hallucinations that might pose a risk. This assessment is crucial in guiding further appropriate interventions to ensure the client's safety and well-being. Instructing the client to ignore the hallucinations (Choice B) may not be effective, as the hallucinations are real to the client. Administering antipsychotic medication (Choice C) may be necessary but should come after assessing the situation. Engaging the client in reality-based activities (Choice D) is important but not the first priority when dealing with auditory hallucinations.
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A client with major depressive disorder is prescribed an antidepressant. Which of the following instructions should the nurse include in the teaching? Select the one that does not apply.
- A. It may take several weeks for the medication to take effect
- B. Avoid alcohol while taking this medication
- C. Discontinue the medication abruptly
- D. You may experience an increase in energy before your mood improves
Correct Answer: C
Rationale: Teaching for a client prescribed an antidepressant should include several key instructions. Firstly, it's important to inform the client that it may take several weeks for the medication to take effect, so they should be patient. Secondly, they should be advised to avoid alcohol while taking the medication as it can interact negatively with antidepressants. Additionally, abrupt discontinuation of antidepressants can lead to withdrawal symptoms and should be avoided. Lastly, clients may experience an increase in energy before their mood improves, which is a common effect of some antidepressants. Regular blood tests are not typically required for most antidepressants, but adherence to the prescribed regimen and reporting any concerning side effects to the healthcare provider are crucial.
A client diagnosed with borderline personality disorder has been admitted to the psychiatric unit after a suicide attempt. Which of the following actions should the nurse take first?
- A. Encourage the client to express feelings about the suicide attempt.
- B. Place the client on one-to-one observation.
- C. Discuss the client's feelings about the suicide attempt.
- D. Encourage the client to participate in group therapy.
Correct Answer: B
Rationale: The initial priority for the nurse is to ensure the safety of the client. Placing the client on one-to-one observation allows for constant monitoring and intervention if there are any signs of self-harm or a worsening condition. This immediate intervention is crucial to prevent further harm. Options A, C, and D involve therapeutic communication and interventions, which are important but should come after ensuring the client's safety.
A healthcare provider is assessing a client with generalized anxiety disorder (GAD). Which of the following findings should the healthcare provider expect? Select one that does not apply.
- A. Restlessness
- B. Fatigue
- C. Excessive worry
- D. Mania
Correct Answer: D
Rationale: In generalized anxiety disorder (GAD), common symptoms include restlessness, fatigue, and excessive worry. These symptoms are typical in individuals with GAD due to persistent and excessive anxiety. Mania, on the other hand, is not a characteristic symptom of GAD. Mania is associated with bipolar disorder and is characterized by distinct features like elevated mood, grandiosity, and impulsivity. Therefore, the correct answer is 'D: Mania,' as it does not align with the expected findings in generalized anxiety disorder.
A client has been diagnosed with generalized anxiety disorder. Which of the following findings should the nurse expect?
- A. Shortness of breath
- B. Chest pain
- C. Excessive worry
- D. Decreased appetite
Correct Answer: C
Rationale: Individuals with generalized anxiety disorder commonly exhibit symptoms like excessive worry, restlessness, and difficulty concentrating. Physical manifestations such as muscle tension and sleep disturbances are also prevalent. Shortness of breath and chest pain are more commonly associated with panic attacks rather than generalized anxiety disorder. Decreased appetite may be present in some cases, but excessive worry is a hallmark characteristic of generalized anxiety disorder.
A client is diagnosed with generalized anxiety disorder (GAD). Which of the following interventions should the nurse implement? Select one that does not apply.
- A. Encourage the client to express their feelings
- B. Teach the client relaxation techniques
- C. Promote regular physical activity
- D. Encourage the use of caffeine
Correct Answer: D
Rationale: Interventions for a client with GAD should include encouraging the client to express their feelings, teaching relaxation techniques, and promoting regular physical activity. Caffeine should be avoided as it can exacerbate anxiety symptoms. Stimulants like caffeine can increase feelings of restlessness and nervousness, making it counterproductive in managing anxiety. Choices A, B, and C are appropriate interventions for managing generalized anxiety disorder by promoting emotional expression, relaxation, and physical well-being, respectively. Choice D, encouraging the use of caffeine, is incorrect as it can worsen anxiety symptoms rather than alleviate them.