Nokea
A female client engages in repeated checks of door and window locks and behavior that prevents her from arriving on time and interfering with her ability to function effectively. Which action should the nurse take?
- A. Ask the client why she checks the locks.
- B. Determine the type and size of the locks.
- C. Discuss checking the time frequently.
- D. Plan a list of activities to be carried out daily.
Correct Answer: D
Rationale: Planning daily activities redirects focus from compulsive checking, reducing anxiety and improving function, suitable for OCD-like behaviors.
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Nurse Notes
0900
Pain assessment completed. The client's pain is 2/10. The client requests sleeping medication for the night. She states that she has horrible thoughts and memories about the house collapsing all the time and that it is keeping her from falling asleep. She states, "I used to be so happy before all of this happened. Now I can't seem to get out of this funk I am in." The client would also prefer to be in a quieter area of the unit as she is currently by the nurses' station and hears talking and alarms constantly.
1100
The nurse reviews the physician's orders for clonazepam and gives the medication as ordered.
1115
Start clonazepam 0.25 mg PO every 12 hours
What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.
- A. Assist the client to the bathroom
- B. Assess mental status regularly
- C. Provide oral care at least twice a day
- D. Screen for orthostatic hypotension
- E. Monitor calcium levels
- F. Have an opioid agonist at the bedside
Correct Answer: B,C,D
Rationale: Assessing mental status, providing oral care, and screening for orthostatic hypotension are appropriate for clonazepam's CNS effects and side effects like dry mouth. Bathroom assistance, calcium monitoring, and opioid agonists are irrelevant.
A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?
- A. Use an incentive spirometer.
- B. Monitor the urinary stream for the decrease in output.
- C. Report when hematuria becomes pink-tinged.
- D. Restrict physical activities.
Correct Answer: C
Rationale: Reporting pink-tinged hematuria is critical to monitor for complications post-TUNA. Spirometry, urinary stream monitoring, and activity restriction are not specific to TUNA discharge.
History and Physical
The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration. Nurses' Notes
0900
Pain assessment completed. The client's pain is 2/10. The client requests sleeping medication for the night. She states that she has horrible thoughts and memories about the house collapsing all the time and that it is keeping her from falling asleep. She states, "I used to be so happy before all of this happened. Now I can't seem to get out of this funk I am in." The client would also prefer to be in a quieter area of the unit as she is currently by the nurses' station and hears talking and alarms constantly.
The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration. The nurse engages the client in conversation about her feelings and some of her coping mechanisms. Click to specify which client statement or behavior is most likely associated with each of the listed defense mechanisms.
- A. The client discusses moving to Hawaii instead of returning to rebuild her house. (Fantasy)
- B. The client seems unemotional when talking about needing to rebuild her house. (Isolation)
- C. The client states that she sometimes forgets why she is in the hospital. (Suppression)
- D. The client is frightened that the hospital will burn down. (Denial)
Correct Answer: A,B,C,D
Rationale: Fantasy (Hawaii move) escapes reality, isolation (unemotional) separates emotions, suppression (forgetting hospitalization) avoids distress, and denial (hospital fire fear) projects trauma.
A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?
- A. Teach the client to develop a plan for daily structured activities.
- B. Encourage the client to exercise.
- C. Suggest that the client develop a list of pleasurable activities.
- D. Provide education on methods to enhance sleep.
Correct Answer: A
Rationale: Structured daily activities provide purpose and combat psychomotor retardation and lack of motivation, key to restoring function.
The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?
- A. Explore changes in life that have occurred after the loss.
- B. Suggest the need for a psychiatric consultation.
- C. Offer a referral to pastoral counseling.
- D. Encourage attending a local support group.
Correct Answer: A
Rationale: Exploring life changes post-loss helps assess the client's grief and tailor interventions, making it the priority action.