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A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?
- A. Ineffective sexual patterns
- B. Disturbed sensory perception
- C. Compromised family coping
- D. Impaired environmental interpretation
Correct Answer: B
Rationale: The client's delusions (e.g., being married to a movie star, brother's intentions) indicate disturbed sensory perception, suggestive of psychosis, which is the priority. Ineffective sexual patterns are not directly indicated. Family coping may be secondary. Impaired environmental interpretation is too broad.
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While sitting in the day-room of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the nurse. The two trade places, and the nurse demonstrates the client's behaviors. Which is the main goal of this therapeutic technique?
- A. Initiate a non-threatening conversation with the client
- B. Allow the client to identify the way he interacts
- C. Dialog about the ineffectiveness of his interactions
- D. Discuss the client's feelings when he responds
Correct Answer: B
Rationale: The technique aims to allow the client to observe his own behaviors, fostering self-awareness. Initiating conversation, dialoguing about ineffectiveness, or discussing feelings are secondary to promoting insight through self-observation.
A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?
- A. Current vital signs
- B. White blood cell count
- C. 24-hour urinary output
- D. Blood sugar level
Correct Answer: A
Rationale: Current vital signs are critical for assessing NMS, a life-threatening side effect of haloperidol, indicated by fever, unstable blood pressure, and tachycardia. White blood cell count, urinary output, and blood sugar are less specific to NMS.
The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?
- A. Alert the assigned staff to closely monitor client and intervene as needed to reduce risk of self-mutilation
- B. Provide the client time alone in the client's room to reduce external stimulation and promote relaxation
- C. Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed
- D. Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm
Correct Answer: A
Rationale: Alerting staff to monitor the client closely addresses the immediate risk of self-harm indicated by increased tension and pacing. Time alone may increase risk. Setting expectations is important but not immediate. Room searches are preventive but not the priority during acute distress.
A client engages in repeated checks of door and window locks and behavior that prevents the client from arriving on time and interfering with the ability to function effectively. Which action should the nurse take?
- A. Determine the type and size of the locks
- B. Plan a list of activities to be carried out daily
- C. Discuss checking the time frequently
- D. Ask the client why the locks are checked so frequently
Correct Answer: B
Rationale: Planning a list of daily activities helps establish a structured routine, reducing time spent on compulsive checking and promoting effective functioning. Determining lock types is irrelevant. Discussing time-checking does not address lock-checking. Asking 'why' may increase frustration, as compulsive behaviors are anxiety-driven.
A male client with a recent diagnosis of bipolar disorder takes lithium carbonate daily. The client informed the school nurse of the desire to live away from home to attend college after graduating in one month. Which information is most important for the nurse to provide the client and his family?
- A. The client should plan to participate in group or individual therapy while at college
- B. The client's serum lithium levels should be routinely evaluated
- C. The client should be aware of the signs and symptoms of his illness
- D. Despite the illness, the client should be able to live away from home
Correct Answer: B
Rationale: Lithium therapy requires regular monitoring of serum levels to ensure therapeutic efficacy and prevent toxicity, especially during transitions like starting college. Therapy and symptom awareness are important but secondary to lithium level monitoring. Independence is a goal but not the primary focus.