Nokea
A female client on a psychiatric unit is sweating profusely while vigorously doing push-ups and then running the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, "I am the boss here. I do what I want." Which nursing problem best supports these observations?
- A. Deficient diversional activity related to excess energy level.
- B. Disturbed personal identity related to grandiosity.
- C. Risk for activity intolerance related to hyperactivity.
- D. Risk for other-directed violence related to disruptive behaviors.
Correct Answer: D
Rationale: The client's behavior of engaging in disruptive and aggressive actions, as well as claiming authority over others in the setting, indicates a risk for other-directed violence. This behavior poses a potential threat to the safety of others in the environment. Choice A is incorrect as the client's behavior is not solely indicative of a lack of diversional activities but rather a more serious issue. Choice B is incorrect as the behavior described does not primarily reflect disturbances in personal identity but rather displays of power and aggression. Choice C is incorrect as the client's actions do not suggest an intolerance to activity but rather an excessive and potentially harmful level of hyperactivity.
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During the admission assessment, a female client requests that her husband be allowed to stay in the room. When the RN notes a discrepancy between the client's verbal and nonverbal communication, what action should the RN take?
- A. Pay close attention to and document the nonverbal messages.
- B. Ask the client's husband to interpret the discrepancy.
- C. Ignore the nonverbal behavior and focus solely on the client's verbal messages.
- D. Integrate the verbal and nonverbal messages and interpret them together.
Correct Answer: A
Rationale: During a client assessment, noting and documenting nonverbal messages is important as it captures the full context of the client's communication. Nonverbal cues can often reveal underlying emotions or issues that may not be expressed verbally. Asking the client's husband to interpret the discrepancy (Choice B) may not be appropriate as it could potentially breach the client's privacy and trust. Ignoring nonverbal behavior (Choice C) can result in missing important cues that could impact the care provided. Integrating verbal and nonverbal messages (Choice D) is beneficial, but the initial step should be to pay close attention and document the nonverbal messages to fully understand the client's communication.
A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. He was divorced one year ago, lost his job four months ago, and suffered a breakup of his current relationship last week. What is the most likely source of this client's current feelings of depression?
- A. Feelings of frustration.
- B. A sense of loss.
- C. Poor self-esteem.
- D. A lack of intimate relationships.
Correct Answer: B
Rationale: The client's recent history of divorce, job loss, and breakup of a current relationship indicates a series of significant losses. These losses are likely the primary source of his feelings of depression, leading to a sense of loss. While feelings of frustration (choice A) and poor self-esteem (choice C) could be contributing factors, the immediate trigger for his current emotional state appears to be the series of losses. A lack of intimate relationships (choice D) may be a consequence of the client's depressive symptoms rather than the root cause in this scenario.
A client with an eating disorder tells the RN, 'I've been eating only 400 calories per day and have been taking diuretics to lose weight.' What is the RN's best response?
- A. "Your diet is very harmful and needs to be changed immediately."
- B. "It's important to monitor your calorie intake carefully."
- C. "Have you noticed any physical effects from this low-calorie diet?"
- D. "The diuretics could be causing your body to lose essential nutrients."
Correct Answer: D
Rationale: The correct response is D. By addressing the potential harm of diuretics and the low-calorie diet, the nurse effectively addresses both aspects of the client's disordered eating behavior. Choice A is too direct and does not provide information on the specific issue of diuretics. Choice B focuses solely on monitoring calorie intake without addressing the use of diuretics. Choice C inquires about physical effects but does not address the overall risks associated with diuretics and low-calorie intake.
A male client with a long history of alcohol dependency arrives in the emergency department describing the feeling of bugs crawling on his body. His BP is 170/102, pulse rate is 110 bpm, and his blood alcohol level (BAL) is 0 mg/dl. Which medication should the nurse administer?
- A. Haloperidol (Haldol)
- B. Thiamine (Vitamin B1)
- C. Diphenhydramine (Benadryl)
- D. Lorazepam (Ativan)
Correct Answer: D
Rationale: In this scenario, the client is experiencing hallucinations and symptoms of alcohol withdrawal. Lorazepam (Ativan) is the appropriate choice as it helps manage withdrawal symptoms, including hallucinations and elevated blood pressure in alcohol-dependent clients. Haloperidol (Haldol) (Choice A) is an antipsychotic but is not the first-line treatment for alcohol withdrawal symptoms. Thiamine (Vitamin B1) (Choice B) is essential in alcohol withdrawal treatment for preventing Wernicke's encephalopathy, but in this case, addressing the acute withdrawal symptoms is the priority. Diphenhydramine (Benadryl) (Choice C) is an antihistamine that may help with itching or mild anxiety but is not the preferred choice for managing alcohol withdrawal symptoms like hallucinations and elevated blood pressure.
A client who has agoraphobia (a fear of crowds) is starting desensitization therapy with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?
- A. Encourage the substitution of positive thoughts for negative ones.
- B. Establish trust by providing a calm, safe environment.
- C. Gradually expose the client to larger crowds.
- D. Encourage deep breathing when anxiety escalates in a crowd.
Correct Answer: B
Rationale: Establishing trust by providing a calm and safe environment is crucial for the success of desensitization therapy in clients with agoraphobia. This approach helps the client feel safe and secure, allowing them to gradually confront their fear of crowds. Encouraging positive thoughts (choice A) is beneficial but not as immediately critical as creating a safe space. Progressively exposing the client to larger crowds (choice C) should occur after trust is established and in a controlled manner. Encouraging deep breathing (choice D) is helpful, but creating a safe environment takes precedence to build a foundation for successful desensitization.