Nokea
A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determines that the client is homeless and slightly suspicious. This client's treatment plan should include what priority problem?
- A. Self-care deficit.
- B. Disturbed sensory perception.
- C. Ineffective community coping.
- D. Acute confusion.
Correct Answer: D
Rationale: The correct answer is 'D: Acute confusion.' In the given scenario, the client is disoriented, disorganized, and confused, indicating acute confusion. This is a priority issue to address for immediate safety and appropriate care. Option A, self-care deficit, is not the priority as the client's safety and mental status take precedence. Option B, disturbed sensory perception, does not align with the client's presentation of confusion. Option C, ineffective community coping, is not the immediate concern as the client's cognitive state needs urgent attention.
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Which client statement suggests to the nurse that the client is using the defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit?
- A. I am here because the police thought I was doing something wrong
- B. At least I hit the wall instead of hitting the psychiatric aide
- C. I want to be here because I know it is the best psychiatric facility
- D. Don't believe everything my family tells you, I am not crazy
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
An elderly client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. Which assessment finding is most concerning for the nurse?
- A. Weight loss of 5 pounds in one week.
- B. Lack of interest in previously enjoyed activities.
- C. Disorganized speech and thought processes.
- D. Severe fatigue and low energy levels.
Correct Answer: C
Rationale: In an elderly client with major depressive disorder, disorganized speech and thought processes are the most concerning assessment finding for the nurse. These symptoms can suggest a more severe condition such as psychosis or cognitive impairment, which require immediate attention and intervention. Weight loss, lack of interest in activities, severe fatigue, and low energy levels are common symptoms of major depressive disorder but do not pose an immediate risk as disorganized speech and thought processes do.
A healthcare provider is evaluating a client's response to a new antianxiety medication. Which client statement indicates a positive response to the medication?
- A. "I feel more relaxed and less anxious."
- B. "I am sleeping less and feel more energetic."
- C. "I have not noticed any changes in my anxiety levels."
- D. "I have more difficulty concentrating than before."
Correct Answer: A
Rationale: The correct answer is A: "I feel more relaxed and less anxious." A positive response to antianxiety medication is characterized by reduced anxiety and increased relaxation. Choice B, which mentions sleeping less and feeling more energetic, suggests potential side effects rather than a positive response to the medication. Choice C indicates no change in anxiety levels, which is not indicative of a positive response. Choice D, mentioning difficulty concentrating, is also a sign of a negative response to antianxiety medication as it may suggest cognitive impairment.
After receiving treatment for anorexia, a student asks the school nurse for permission to work in the school cafeteria as part of the school's work-study program. What action should the nurse take?
- A. Recommend assignment to the receptionist's office.
- B. Suggest that the student work in the athletic department.
- C. Refer the student to a psychiatrist for further discussion.
- D. Determine the parents' opinion of the work assignment.
Correct Answer: A
Rationale: Clients with anorexia are often fixated on food and exercise, which can exacerbate their condition. By recommending assignment to the receptionist's office, the nurse provides an environment that minimizes exposure to food-related triggers. Working in the cafeteria may intensify the student's preoccupation with food, making it an unsuitable choice. Referring the student to a psychiatrist without exploring less triggering work options first may not be necessary. Determining the parents' opinion is important, but in this context, the focus should be on selecting a work environment that supports the student's recovery.
A client is agitated and physically aggressive. What action should the RN take first?
- A. Calmly inform the client that they will be placed in seclusion if they do not calm down.
- B. Discuss with the client the reasons for their agitation and aggression.
- C. Tell the client that physical aggression is not acceptable and must stop.
- D. Seek assistance from other staff members and follow the facility's protocol.
Correct Answer: D
Rationale: In a situation where a client is agitated and physically aggressive, the priority for the RN is to ensure the safety of the client and others. Seeking assistance from other staff members is crucial as it allows for a prompt response to manage the situation effectively and according to the facility's protocol. Choices A, B, and C do not address the immediate need for safety or involve the collaboration of other staff members, which is essential in handling aggressive behaviors in a healthcare setting.