Nokea
A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to verbally attack other clients. What intervention is most appropriate for the RN to use to manage the client’s behavior?
- A. Assist the client to a safe area to avoid injury.
- B. Establish clear and firm limits with the client.
- C. Offer medication to help calm the client down.
- D. Speak with the client in a calm, non-threatening manner.
Correct Answer: A
Rationale: The correct answer is A: Assist the client to a safe area to avoid injury. This intervention is most appropriate because the client is engaging in potentially harmful behaviors such as vigorous physical activity and verbal aggression. By moving the client to a safe area, the nurse can prevent the client from causing harm to themselves or others. It is essential to prioritize physical safety in situations like this.
Option B, establishing clear and firm limits, may not be effective in the moment when the client is in an agitated state and may not respond well to verbal directives. Option C, offering medication, should not be the first response as it may not address the immediate safety concerns. Option D, speaking calmly, may not be enough to de-escalate the situation when the client is in a heightened state of agitation.
Overall, ensuring the physical safety of the client and others is the priority in this scenario, making option A the most appropriate intervention.
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To provide effective care for the patient diagnosed with schizophrenia, the nurse should frequently assess for which associated condition? Select all that apply.
- A. Alcohol use disorder
- B. Major depressive disorder
- C. Stomach cancer
- D. Polydipsia
Correct Answer: A
Rationale: The correct answer is A: Alcohol use disorder. Patients with schizophrenia are at higher risk for co-occurring substance use disorders, including alcohol use disorder. Assessing for alcohol use is crucial as it can worsen symptoms and interfere with treatment. Major depressive disorder (B) is a common comorbidity but is not specific to schizophrenia. Stomach cancer (C) is not directly associated with schizophrenia. Polydipsia (D), excessive thirst, can be seen in schizophrenia due to medication side effects but is not a primary associated condition.
Carolina is surprised when her patient does not show for a regularly scheduled appointment. When contacted, the patient states, 'I don’t need to come see you anymore. I have found a therapy app on my phone that I love.' How should Carolina respond to this news?
- A. That sounds exciting, would you be willing to visit and show me the app?
- B. At this time, there is no real evidence that the app can replace our therapy.
- C. I am not sure that is a good idea right now, we are so close to progress.
- D. Why would you think that is a better option than meeting with me?
Correct Answer: A
Rationale: Rationale for Choice A: Carolina should respond positively to the patient's enthusiasm about the therapy app to maintain rapport. By asking the patient to show the app, Carolina displays genuine interest and open-mindedness, fostering a collaborative discussion. This approach allows Carolina to understand the patient's perspective and potentially integrate the app into the therapy if suitable. It also shows respect for the patient's autonomy in seeking alternative support.
Summary of other choices:
B: This response is dismissive and does not acknowledge the patient's preferences, potentially damaging the therapeutic relationship.
C: This response may come off as controlling or resistant, risking alienating the patient and hindering progress.
D: This response is confrontational and may make the patient defensive, leading to communication breakdown rather than exploration of alternatives.
The RN is providing care for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the RN use when changing this client’s dressing?
- A. Provide detailed thorough explanations when cleansing wound.
- B. Perform the dressing change in a non-judgmental manner.
- C. Ask in a non-threatening manner why the client cut own abdomen.
- D. Request another staff member assist with the dressing change.
Correct Answer: B
Rationale: The correct answer is B: Perform the dressing change in a non-judgmental manner. When caring for a client with borderline personality disorder who has self-inflicted injuries, it is crucial to approach the situation with empathy and without passing judgment. This approach helps build trust, maintains the therapeutic relationship, and encourages open communication. Providing detailed explanations (choice A) may overwhelm the client. Asking about the self-inflicted behavior (choice C) in a non-threatening manner can be appropriate but should not be the primary focus during the dressing change. Requesting another staff member's assistance (choice D) may not be necessary if the RN can handle the situation effectively.
When should a nurse be most alert to the possibility of communication errors resulting in harm to the patient?
- A. Change of shift report
- B. Admission interviews
- C. One-to-one conversations with patients
- D. Conversations with patient families
Correct Answer: A
Rationale: The correct answer is A: Change of shift report. During this crucial handover period, communication errors can occur due to the transfer of information between nurses, leading to potential harm to the patient. This is when important patient details, care plans, and vital information are shared, making it a critical time for accurate and effective communication. Nurses must be vigilant to ensure clear and concise communication to prevent errors.
Summary of why the other choices are incorrect:
B: Admission interviews - While important, communication errors during admission interviews may not have as immediate impact on patient safety as during a shift change report.
C: One-to-one conversations with patients - These interactions are also important, but errors in communication may not have the same potential for harm as during a shift change report.
D: Conversations with patient families - While communication with families is vital, errors during these conversations may not always directly lead to harm as in a shift change report.
A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the deceased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time?
- A. Not sleeping for several days.
- B. Wishing to be with spouse.
- C. Lack of interest in usual activities.
- D. Eating very little.
Correct Answer: A
Rationale: The correct answer is A: Not sleeping for several days. This is the most important client statement to explore because it indicates the client may be experiencing severe sleep disturbances, which can have a significant impact on their mental and physical health. Lack of sleep can exacerbate symptoms of depression and increase the risk of self-harm or suicide. Therefore, the RN should prioritize exploring this issue to assess the client's safety and provide appropriate interventions.
Choices B, C, and D are also important concerns related to grief and depression, but the immediate risk associated with severe sleep deprivation makes option A the most critical to address first. It is essential to address all client statements eventually, but the urgency of the client's sleep disturbances requires immediate attention.