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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 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.
Which of the following are characteristics of borderline personality disorder? Select one that does not apply.
- A. Intense fear of abandonment
- B. Unstable relationships
- C. Impulsivity
- D. Grandiosity
Correct Answer: D
Rationale: Borderline personality disorder is characterized by an intense fear of abandonment, unstable relationships, impulsivity, and chronic feelings of emptiness. Grandiosity, which involves an exaggerated sense of self-importance and superiority, is more commonly associated with narcissistic personality disorder rather than borderline personality disorder. Therefore, the correct answer is D.
A client has been prescribed sertraline (Zoloft) for depression. Which of the following instructions should the nurse include in the discharge teaching?
- A. Take the medication in the morning to avoid daytime drowsiness.
- B. Avoid drinking alcohol while taking this medication.
- C. Take the medication with a full glass of water.
- D. Stop taking the medication if you feel better.
Correct Answer: B
Rationale: The correct instruction for the nurse to include in the discharge teaching is to advise the client to avoid drinking alcohol while taking sertraline (Zoloft). Alcohol can exacerbate the side effects of the medication, such as drowsiness and dizziness, and may also decrease the effectiveness of the treatment for depression. Choice A is incorrect as sertraline is usually taken in the morning. Choice C is not a specific instruction related to the medication. Choice D is incorrect as abruptly stopping sertraline can lead to withdrawal symptoms and should only be done under medical supervision.
A client is diagnosed with obsessive-compulsive disorder (OCD). Which of the following interventions should the nurse include in the care plan? Select one that does not apply.
- A. Allow the client to perform rituals initially
- B. Set limits on the time allowed for rituals
- C. Encourage the client to verbalize feelings
- D. Provide a structured schedule of activities
Correct Answer: A
Rationale: Interventions for a client with OCD should include allowing the client to perform rituals initially, setting limits on the time allowed for rituals, encouraging the client to verbalize feelings, and providing a structured schedule of activities. Allowing the client to perform rituals is an essential part of managing OCD and should not be restricted in the initial stages of care. Setting limits on the time for rituals helps prevent excessive engagement in them. Encouraging the client to verbalize feelings promotes emotional expression and processing. Providing a structured schedule of activities helps establish routine and predictability, which can be beneficial for individuals with OCD.
A client has been diagnosed with generalized anxiety disorder and expresses worrying about their job, family, and health, feeling a loss of control. What should the nurse do first?
- A. Administer a prescribed antianxiety medication.
- B. Encourage the client to attend a support group.
- C. Identify triggers of the client's anxiety.
- D. Teach the client deep breathing techniques.
Correct Answer: D
Rationale: The initial step for the nurse is to teach the client deep breathing techniques to aid in managing anxiety symptoms. Deep breathing exercises can help the client relax, reduce anxiety levels, and regain a sense of control. This intervention is non-invasive, empowering the client to develop a coping strategy for immediate use when feeling overwhelmed by anxiety. Administering medication (Choice A) should not be the first action unless the client is in severe distress. Encouraging attendance at a support group (Choice B) and identifying triggers of anxiety (Choice C) are important but teaching coping strategies like deep breathing comes first to help the client feel more in control of managing their anxiety.