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A client with schizophrenia is experiencing auditory hallucinations. Which nursing intervention should the nurse implement to address this symptom?
- A. Encourage the client to express feelings about the hallucinations.
- B. Distract the client from the hallucinations.
- C. Provide reality-based feedback about the hallucinations.
- D. Encourage the client to ignore the hallucinations.
Correct Answer: C
Rationale: The correct intervention for a client experiencing auditory hallucinations in schizophrenia is to provide reality-based feedback about the hallucinations. By providing reality-based feedback, the nurse helps the client differentiate between what is real and what is not, which can help decrease the distress and impact of the hallucinations on the client's perception of reality. Encouraging the client to express feelings (Choice A) may not directly address the hallucinations. Distracting the client (Choice B) may temporarily alleviate the symptoms but does not help the client differentiate reality from hallucinations. Encouraging the client to ignore the hallucinations (Choice D) may not be effective as the client may struggle to do so without appropriate guidance.
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A client with obsessive-compulsive disorder (OCD) is being cared for by a nurse. Which intervention should the nurse implement to help the client manage compulsive behaviors?
- A. Encourage the client to suppress compulsive behaviors.
- B. Allow the client to perform compulsive behaviors with limits.
- C. Teach the client relaxation techniques to manage anxiety.
- D. Discourage the client from performing compulsive behaviors.
Correct Answer: B
Rationale: Allowing the client to perform compulsive behaviors with limits is a therapeutic intervention for managing OCD. This approach grants the client some autonomy while ensuring that the behaviors do not excessively disrupt daily life. Setting boundaries helps structure the behaviors, decreasing anxiety and distress associated with OCD. Encouraging the client to suppress compulsive behaviors (choice A) may lead to increased anxiety and potential worsening of symptoms. Teaching relaxation techniques (choice C) is beneficial for managing anxiety in general but may not directly address the compulsive behaviors. Discouraging the client from performing compulsive behaviors (choice D) without providing alternative strategies or support may increase distress and resistance.
A client with depression is experiencing anhedonia. Which statement by the client reflects this symptom?
- A. I feel so anxious all the time.
- B. I don't enjoy the things I used to love.
- C. I can't concentrate on anything.
- D. I have trouble sleeping through the night.
Correct Answer: B
Rationale: Anhedonia is the inability to experience pleasure from activities usually found enjoyable. The statement 'I don't enjoy the things I used to love' directly reflects this symptom as the client is expressing a lack of pleasure from previously enjoyable activities. Choices A, C, and D do not specifically relate to anhedonia but rather indicate symptoms of anxiety, concentration difficulties, and sleep disturbances, respectively.
A client with major depressive disorder expresses feelings of hopelessness. Which nursing intervention should the nurse implement to address these feelings?
- A. Encourage the client to engage in physical activity.
- B. Provide opportunities for the client to make decisions.
- C. Help the client identify positive aspects of their life.
- D. Encourage the client to verbalize feelings of hopelessness.
Correct Answer: C
Rationale: When a client with major depressive disorder expresses feelings of hopelessness, helping them identify positive aspects of their life can be an effective nursing intervention. This approach can assist in shifting their focus from negativity to positivity, promoting a sense of hope and potentially improving their overall outlook and well-being. By highlighting the positive aspects, the nurse can support the client in recognizing reasons for hope and encourage a more optimistic perspective, which can aid in addressing and alleviating feelings of hopelessness. Encouraging physical activity (Choice A) may be beneficial for overall well-being but may not directly address feelings of hopelessness. Providing opportunities for decision-making (Choice B) can empower the client but may not specifically target feelings of hopelessness. Encouraging verbalization of feelings (Choice D) is important but may not be as effective as helping the client shift their focus to positive aspects of life.
A client has been prescribed a monoamine oxidase inhibitor (MAOI). Which dietary restriction should the nurse emphasize during discharge instructions?
- A. Avoid foods high in potassium.
- B. Avoid foods high in calcium.
- C. Avoid foods high in tyramine.
- D. Avoid foods high in sodium.
Correct Answer: C
Rationale: The correct answer is C: Avoid foods high in tyramine. Clients taking MAOIs should avoid foods high in tyramine to prevent hypertensive crisis. Tyramine is found in aged, fermented, or spoiled foods. Choices A, B, and D are incorrect because potassium, calcium, and sodium restrictions are not specifically required for clients taking MAOIs.
A client diagnosed with panic disorder is receiving discharge teaching from a healthcare provider. Which statement by the client indicates an accurate understanding of the teaching?
- A. I should avoid caffeine and other stimulants.
- B. I should take my medication only when I feel anxious.
- C. I should use relaxation techniques to manage anxiety.
- D. I should avoid exercising to prevent triggering anxiety.
Correct Answer: A
Rationale: The correct answer is A. Avoiding caffeine and other stimulants is crucial for clients with panic disorder as these substances can exacerbate anxiety symptoms. Caffeine can trigger or worsen anxiety, leading to increased heart rate and restlessness. By eliminating stimulants, the client can better manage their anxiety levels and reduce the risk of panic attacks. Choices B, C, and D are incorrect because taking medication only when feeling anxious may lead to inconsistent treatment, using relaxation techniques alone may not be sufficient for managing panic disorder, and avoiding exercise can actually be counterproductive as regular physical activity can help reduce anxiety and stress levels.