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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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A client with obsessive-compulsive disorder (OCD) repeatedly checks to see if the door is locked and asks for reassurance that it is locked. What is the most appropriate intervention by the RN to address this behavior?
- A. Set a specific limit on the number of times the client can check the door.
- B. Help the client find an alternative activity to perform.
- C. Provide consistent reassurance that the door is locked.
- D. Ignore the checking behavior and focus on other behaviors.
Correct Answer: A
Rationale: The correct answer is A: Set a specific limit on the number of times the client can check the door. This intervention helps establish boundaries and structure for the client, which can assist in reducing compulsive behaviors. By setting a specific limit, the client is encouraged to gradually decrease the checking behavior and learn to cope with the anxiety associated with uncertainty. This approach promotes independence and empowerment for the client.
Choice B is incorrect because finding an alternative activity does not directly address the obsessive checking behavior. Choice C is incorrect as providing consistent reassurance reinforces the compulsive behavior. Choice D is incorrect because ignoring the behavior does not actively address or help decrease the compulsive checking.
Which statement demonstrates a well-structured attempt at limit setting?
- A. Hitting me when you are angry is unacceptable.
- B. I expect you to behave yourself during dinner.
- C. Come here, right now!
- D. Good boys don’t bite.
Correct Answer: A
Rationale: The correct answer is A because it clearly communicates the behavior that is unacceptable (hitting when angry) and sets a clear boundary. It addresses the specific behavior and its consequences without being vague or ambiguous. Choice B lacks specificity, choice C is a command without explaining the reason for the request, and choice D uses shaming language which is not effective in setting limits. Choices E, F, and G are irrelevant as they are not provided. Overall, choice A demonstrates a well-structured attempt at limit setting by being clear, specific, and focusing on the behavior that needs to change.
Pablo is a homeless adult who has no family connection. Pablo passed out on the street and emergency medical services took him to the hospital where he expresses a wish to die. The physician recognizes evidence of substance use problems and mental health issues and recommends inpatient treatment for Pablo. What is the rationale for this treatment choice? Select all that apply.
- A. Intermittent supervision is available in inpatient settings.
- B. He requires stabilization of multiple symptoms.
- C. He has nutritional and self-care needs.
- D. Medication adherence will be mandated.
Correct Answer: A
Rationale: The correct answer is A: Intermittent supervision is available in inpatient settings. In an inpatient treatment setting, Pablo can receive continuous monitoring and supervision, ensuring his safety and well-being. This is crucial for someone like Pablo who is homeless, has substance use issues, and expressed a wish to die. Inpatient treatment can provide a controlled environment where his physical and mental health can be closely monitored, and immediate interventions can be implemented if needed.
Incorrect choices:
B: While stabilization of multiple symptoms is important, the key factor here is the need for constant supervision, which is better provided in an inpatient setting.
C: Although nutritional and self-care needs are important, the primary concern in this case is Pablo's mental health and safety, which can be better addressed in an inpatient setting.
D: While medication adherence is important, it is not the primary reason for recommending inpatient treatment for Pablo. The need for supervision and monitoring takes precedence.
A nurse is caring for a client who was admitted for alcohol disorder. which one of the following require follow uo by the nurse? select all that apply
- A. Cardiac assessment
- B. Smoking history
- C. Genitourinary assessment
- D. Neurological assessment
- F. Client's recent loss
- G. Gastrointestinal assess,ment
Correct Answer: B
Rationale: The correct answer is B: Smoking history. This requires follow-up by the nurse because smoking can exacerbate alcohol-related health issues. The nurse needs to assess smoking habits to provide comprehensive care and address potential risks.
A: Cardiac assessment is important but not specifically related to alcohol disorder.
C: Genitourinary assessment may be important but is not a priority in this case.
D: Neurological assessment is crucial in alcohol disorder but is not the focus of the question.
F: Client's recent loss is important but not directly related to the client's alcohol disorder.
G: Gastrointestinal assessment is relevant but not a priority in this scenario.
What assessment question will provide the nurse with information regarding the effects of a woman’s circadian rhythms on her quality of life?
- A. I notice that you frowned and avoided eye contact just now. Don’t you feel well?
- B. Does your heart ever seem to skip a beat?
- C. When was the last time you had a fever?
- D. Do you have problems urinating?
- E. How much sleep do you usually get each night?
Correct Answer: E
Rationale: The correct answer is E: How much sleep do you usually get each night? This question directly addresses the effects of circadian rhythms on the woman's quality of life as sleep patterns are regulated by these rhythms. By understanding her typical sleep duration, the nurse can assess if her circadian rhythms are impacting her quality of life. Choices A, B, C, and D do not specifically address circadian rhythms and their effects. A focuses on general well-being, B on cardiac issues, C on fever, and D on urinary problems. These options do not provide relevant information about circadian rhythms and their impact on quality of life, making them incorrect in this context.