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A female client with bulimia nervosa is admitted to the hospital. Which intervention should the nurse include in the plan of care?
- A. Allow the client to eat meals alone to reduce stress.
- B. Observe the client for 30 minutes after meals.
- C. Provide the client with a high-calorie diet.
- D. Encourage the client to weigh herself daily.
Correct Answer: B
Rationale: The correct intervention for a client with bulimia nervosa is to observe the client for 30 minutes after meals. This helps prevent purging behaviors, such as vomiting or using laxatives, which are common in bulimia nervosa. Choice A is incorrect because eating meals alone may enable the client to engage in purging behaviors without being observed. Choice C is incorrect as a high-calorie diet may exacerbate the client's concerns about weight gain. Choice D is incorrect because encouraging daily weigh-ins can reinforce obsessive thoughts about weight and body image.
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A client with schizophrenia is being treated with haloperidol (Haldol). The LPN/LVN observes the client pacing in the hallway and appearing anxious. What should the nurse do first?
- A. Ask the client to sit down and relax.
- B. Administer a PRN dose of antipsychotic medication.
- C. Encourage the client to talk about what is making him anxious.
- D. Monitor the client for adverse reactions to the medication.
Correct Answer: B
Rationale: Administering a PRN dose of antipsychotic medication is the first action the nurse should take to manage symptoms of anxiety in a client being treated with haloperidol. The priority is to address the client's escalating anxiety and pacing behavior, which can be managed effectively by providing additional antipsychotic medication. Asking the client to sit down and relax (Choice A) may not be effective if the anxiety is due to inadequate medication levels. Encouraging the client to talk about what is making him anxious (Choice C) may not be beneficial in this acute situation and can be considered after addressing the immediate need for symptom management. Monitoring for adverse reactions (Choice D) is important but is not the first action to take when the client is showing signs of increasing anxiety and agitation.
A client who is diagnosed with schizophrenia is admitted to the hospital. The nurse assesses the client's mental status. Which assessment finding is most characteristic of a client with schizophrenia?
- A. Mood swings.
- B. Extreme sadness.
- C. Manipulative behavior.
- D. Flat affect.
Correct Answer: D
Rationale: The correct answer is D: Flat affect. Flat affect, which is a lack of emotional expression, is highly characteristic of schizophrenia. Mood swings (choice A) are more indicative of mood disorders rather than schizophrenia. Extreme sadness (choice B) could be seen in depression but is not as specific to schizophrenia. Manipulative behavior (choice C) is not a defining characteristic of schizophrenia; it may be seen in various psychiatric conditions but is not the most characteristic feature of schizophrenia.
An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam (Xanax). During the health assessment, the client complains of chest pain. Which action should the RN take first?
- A. Refer the client to the cardiology unit.
- B. Obtain the client's blood pressure.
- C. Assess the client for substance abuse.
- D. Determine if Xanax was taken recently.
Correct Answer: D
Rationale: Determining if Xanax was taken recently is crucial as it helps assess whether the chest pain is related to medication use or another issue, guiding appropriate immediate care. This action can provide essential information to address the client's current complaint effectively. Referring the client to the cardiology unit (Choice A) may be premature without assessing the Xanax use first. While obtaining the client's blood pressure (Choice B) is important, it is not the priority when the client presents with chest pain and a history of taking Xanax. Assessing the client for substance abuse (Choice C) is also important but is secondary to first determining the potential link between Xanax and the chest pain.
A female client with depression attends group and states that she sometimes misses her medication appointments because she feels very anxious about riding the bus. Which statement is the nurse's best response?
- A. Can your case manager take you to your appointments?
- B. Take your medication for anxiety before you ride the bus.
- C. Let's talk about what happens when you feel very anxious.
- D. What are some ways that you can cope with your anxiety?
Correct Answer: D
Rationale: The best response is to explore ways for the client to cope with anxiety (D). The nurse should encourage problem-solving rather than dependence on the case manager (A) for transportation. While taking medication for anxiety before riding the bus may be helpful, addressing coping strategies should come first (B). Although discussing the feelings of anxiety can be therapeutic (C), the most appropriate approach is to engage the client in finding ways to manage her anxiety effectively.
A client with schizophrenia is experiencing auditory hallucinations. What is the most appropriate nursing intervention?
- A. Encourage the client to ignore the voices.
- B. Ask the client what the voices are saying.
- C. Distract the client with a new activity.
- D. Tell the client that the voices are not real.
Correct Answer: B
Rationale: Asking the client what the voices are saying is the most appropriate intervention as it helps the nurse assess the content of the hallucinations and the potential risk they may pose. Encouraging the client to ignore the voices (Choice A) may not address the underlying issue or provide valuable information for the nurse. Distracting the client with a new activity (Choice C) may temporarily divert attention but does not address the hallucinations. Telling the client that the voices are not real (Choice D) may invalidate the client's experience and can lead to distrust in the therapeutic relationship.