Nokea
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.
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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.
A young female client is admitted to the emergency room because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record as the client's chief complaint?
- A. Client claims that she was forced to participate in sexual intercourse
- B. Client reported that she had sexual relations against her will
- C. Client has been sexually assaulted
- D. Client states, 'My date raped me tonight'
Correct Answer: D
Rationale: Client states, 'My date raped me tonight' is the most accurate and objective, using the client's own words to document the chief complaint without implying doubt ('claims') or minimizing the trauma. 'Sexual assault' is accurate but less specific.
The nurse is performing intake interviews at a psychiatric clinic. A client with a known history of drug abuse reports having had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction?
- A. Alcohol
- B. Benzodiazepine
- C. Methamphetamine
- D. Marijuana
Correct Answer: C
Rationale: Methamphetamine use is known to cause significant cardiovascular effects, including increased heart rate, blood pressure, and vasoconstriction, which can lead to myocardial infarction. Excessive alcohol consumption can contribute to cardiovascular issues but is less potent than methamphetamine. Benzodiazepines primarily affect the central nervous system, not the cardiovascular system. Marijuana has cardiovascular effects but is generally less risky than methamphetamine.
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.
During the admission assessment to the mental health unit, a client reports that the people at the office, where the client works, are antagonistic and the client is thinking of shooting the supervisor. The client asks the nurse not to reveal this to anyone else. The nurse immediately notifies the client's therapist and other team members of the client's thoughts. The therapist then calls the client's supervisor and shares the client's thoughts about shooting the supervisor. Which outcome is best based on the action of the nurse?
- A. The nurse is reprimanded for divulging confidential patient information without obtaining informed consent
- B. Both the nurse and therapist are reprimanded for divulging confidential patient information to others
- C. The nurse and therapist will be asked to educate other team members on appropriate sharing of client information
- D. The therapist is reprimanded for divulging confidential patient information without obtaining consent
Correct Answer: C
Rationale: The nurse appropriately shared the threat with the team to ensure safety, but the therapist's disclosure to the supervisor may breach confidentiality. Educating team members on appropriate information sharing balances safety and privacy. Reprimands are less constructive unless clear violations occurred.