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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 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: Assisting the client to a safe area is the most appropriate intervention in this scenario. This action helps prevent injury to the client and others while allowing for de-escalation in a controlled environment. While establishing clear and firm limits (Choice B) may be necessary in some situations, the immediate priority here is safety. Offering medication (Choice C) should not be the first response unless the situation escalates further and poses a risk to the client or others. Speaking with the client in a calm, non-threatening manner (Choice D) may not be effective when the client is in an agitated state and engaging in risky behavior.
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When preparing to administer a domestic violence screening tool to a female client, which statement should the RN provide?
- A. If your partner is abusing you, I need to ask these questions.
- B. State law mandates that I ask if you are a victim of domestic violence.
- C. The healthcare provider needs to know if you are experiencing any domestic abuse.
- D. All clients are screened for domestic abuse because it is common in our society.
Correct Answer: D
Rationale: The correct answer is D because screening all clients for domestic abuse helps normalize the process and reduces the stigma, encouraging honest responses. Choice A is not the best option as it may come off as accusatory and can deter the client from being open. Choice B, mentioning state law, may create fear or pressure, affecting the client's response. Choice C focuses on the healthcare provider's needs rather than emphasizing the client's well-being, which may not facilitate open communication.
The healthcare provider is assessing a client who has been taking an antidepressant for several months. Which symptom would suggest that the medication is working?
- A. Improved mood and increased energy.
- B. Increased appetite and weight gain.
- C. Decreased anxiety and agitation.
- D. Enhanced sleep patterns and vivid dreams.
Correct Answer: A
Rationale: When assessing the effectiveness of an antidepressant, improved mood and increased energy are positive indicators that the medication is working. Choice B, increased appetite and weight gain, is more commonly associated with side effects of some antidepressants, such as certain tricyclic antidepressants. Choice C, decreased anxiety and agitation, could be related to the therapeutic effects of antidepressants in treating anxiety disorders but may not specifically indicate the efficacy of the medication for depression. Choice D, enhanced sleep patterns and vivid dreams, while changes in sleep patterns can be influenced by antidepressants, they are not the primary indicators of antidepressant efficacy. Therefore, the correct choice is A as it directly reflects the desired outcomes of antidepressant therapy.
A female client engages in repeated checks of door and window locks, a behavior that prevents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take?
- A. Ask the client why she checks the locks.
- B. Discuss checking the time frequently.
- C. Determine the type and size of the locks.
- D. Plan a list of activities to be carried out daily.
Correct Answer: D
Rationale: Planning a list of daily activities can help the client manage her time better and reduce the impact of her compulsive behaviors. Option A is incorrect because simply asking why the client checks the locks may not address the underlying issue effectively. Option B is not relevant to the compulsive behavior of checking locks. Option C does not directly address the client's compulsive behavior but focuses on the physical attributes of the locks.
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.
A male client comes to the emergency center with an erection that will not resolve. The client reports that he is taking trazodone (Desyrel) for insomnia. Which information is most important for the nurse to ask this client?
- A. Have you taken any medication for erectile dysfunction?
- B. Are you experiencing any other sexual dysfunctions or problems?
- C. When was the last time you consumed an alcoholic beverage?
- D. Do you have a history of angina or high blood pressure?
Correct Answer: B
Rationale: In this scenario, the most important question for the nurse to ask the client is whether he is experiencing any other sexual dysfunctions or problems. This inquiry is crucial as it can help in determining if the persistent erection is a side effect of trazodone. Asking about medication for erectile dysfunction (Choice A) may not provide relevant information in this case, as the focus is on the potential side effects of trazodone. Inquiring about the last time the client consumed alcohol (Choice C) is not directly related to the situation at hand. Questioning about a history of angina or high blood pressure (Choice D) is important for overall assessment but is not as directly relevant to the immediate concern of the persistent erection potentially caused by trazodone.