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A client with schizophrenia who has been stabilized on medication is being discharged from the hospital. What discharge teaching is most important for the LPN/LVN to reinforce?
- A. The importance of adhering to the prescribed medication regimen.
- B. How to recognize early signs of relapse.
- C. The need to continue follow-up appointments with the healthcare provider.
- D. The importance of maintaining a healthy lifestyle, including proper diet and exercise.
Correct Answer: A
Rationale: The correct answer is A. Reinforcing the importance of adhering to the prescribed medication regimen is crucial for preventing relapse in clients with schizophrenia. Compliance with medication is essential in managing the symptoms and preventing a worsening of the condition. Choice B, recognizing early signs of relapse, is important but secondary to ensuring medication adherence. Choice C, follow-up appointments, is also important but not as critical as medication compliance immediately post-discharge. Choice D, maintaining a healthy lifestyle, is beneficial for overall health but is not as directly linked to preventing relapse in schizophrenia as medication adherence.
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A female client presents to the emergency center with confusion, emotional numbness, and expresses to the nurse a feeling of disbelief that she was raped. The nurse determines the client is in the acute phase of rape-trauma syndrome. What action should the nurse implement first?
- A. Secure samples of vaginal hair combings.
- B. Offer prophylactic antibiotic medication.
- C. Explain the rape protocol to the client.
- D. Implement crisis intervention counseling.
Correct Answer: C
Rationale: In cases of rape-trauma syndrome, it is crucial to provide clear information about what to expect during the examination and treatment. This can help the client regain a sense of control and reduce anxiety. Explaining the rape protocol to the client should be the first action to implement. Option A is not the priority at this stage as the immediate focus is on addressing the client's emotional needs and providing support. Option B is not the first action unless medically indicated. Option D, crisis intervention counseling, is important but should come after providing essential information and support to the client.
A client with obsessive-compulsive disorder (OCD) spends several hours a day washing his hands. What is the most therapeutic nursing intervention?
- A. Allow the client to continue the behavior to reduce anxiety.
- B. Schedule specific times for handwashing.
- C. Encourage the client to discuss the thoughts and feelings behind the behavior.
- D. Restrict the client's access to soap and water.
Correct Answer: C
Rationale: Encouraging the client to discuss the thoughts and feelings behind the behavior is the most therapeutic nursing intervention for a client with OCD who excessively washes hands. This approach can help the client understand the underlying reasons for the behavior, address the associated anxiety, and work toward behavior modification. Choices A, allowing the behavior to continue, and D, restricting access to soap and water, do not address the root cause of the behavior and may exacerbate anxiety. Choice B, scheduling specific times for handwashing, does not address the underlying emotional factors contributing to the behavior and may not effectively reduce the client's anxiety.
A 30-year-old sales manager tells the nurse, 'I am thinking about a job change. I don't feel like I am living up to my potential.' Which of Maslow's developmental stages is the sales manager attempting to achieve?
- A. Self-Actualization
- B. Loving and Belonging
- C. Basic Needs
- D. Safety and Security
Correct Answer: A
Rationale: The correct answer is 'Self-Actualization.' Self-actualization is the highest level of Maslow's hierarchy of needs, focusing on fulfilling one's full potential and achieving personal growth. In this scenario, the sales manager expressing a desire for a job change because they don't feel they are living up to their potential aligns with the characteristics of self-actualization. Choices B, C, and D represent lower levels of Maslow's hierarchy: 'Loving and Belonging' pertains to social needs, 'Basic Needs' encompass physiological and safety needs, and 'Safety and Security' are fundamental needs related to protection and stability.
A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. Which approach will the nurse take?
- A. Call a staff member to escort the client to his room.
- B. Tell the client to talk to his healthcare provider about his privileges.
- C. Remind the client of the unit rules.
- D. Ignore the client's inappropriate behavior.
Correct Answer: C
Rationale: (C) is the correct approach in this situation as it reinforces unit rules, setting clear boundaries and expectations. By reminding the client of the unit rules, the nurse is helping to maintain a safe and structured environment within the drug rehabilitation unit. (A) is unnecessary since the client's behavior does not warrant immediate physical intervention. (B) is not ideal because the client's privileges have already been explained, and suggesting he speak to his healthcare provider may not address the immediate issue. (D) is not appropriate as addressing inappropriate behavior is essential in a therapeutic setting.
The LPN/LVN is caring for a client who was recently diagnosed with a mental illness. The client asks, 'Will I be able to live a normal life?' What is the best response for the nurse to provide?
- A. Yes, you will be able to live a normal life.
- B. Many people with mental illness lead full and productive lives.
- C. It will depend on your treatment and the choices you make.
- D. There is no normal; everyone is unique in their own way.
Correct Answer: C
Rationale: The best response for the nurse is to provide the client with hope while acknowledging the importance of their treatment and choices. Choice C addresses the client's concern by highlighting the impact of their treatment and personal choices on their future. It encourages personal responsibility and active participation in their recovery. Choices A and B may sound reassuring, but they do not empower the client to take an active role in their well-being. Choice D, while promoting individuality, does not directly address the client's question about living a normal life after a mental illness diagnosis.