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A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit's day room. Which action should the nurse implement first?
- A. Sit in the chair next to the client.
- B. Listen to what the client is saying.
- C. Escort the client to his room.
- D. Administer a PRN sedative.
Correct Answer: B
Rationale: Listening to what the client is saying helps understand the hallucinations' content, providing insight for appropriate intervention.
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While visiting the community mental health center, a client with a diagnosis of major depressive disorder asks the nurse if what is shared with the staff will be shared with family members. How should the nurse respond to this client?
- A. Provide the client with a written hospital policy regarding privacy of information laws.
- B. Tell the client that confidentiality will be maintained, except when one's safety is threatened.
- C. Nod in the affirmative, but make no verbal commitment to the client.
- D. Assure the client that information provided will be shared with the staff only.
Correct Answer: B
Rationale: This response provides accurate information about confidentiality while acknowledging exceptions when safety is at risk, addressing the client's concern clearly.
A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client's rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?
- A. Disrupts group activities.
- B. Wanders into client's rooms.
- C. Talks with nonsensical words.
- D. Refuses antipsychotic medications.
Correct Answer: B
Rationale: Wandering into client's rooms poses a safety risk to both the client and others, indicating a need for constant observation to prevent potential harm.
The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the client's history should the nurse further explore?
- A. Family history of dementia.
- B. Witness to an accident.
- C. Alcohol use.
- D. Inadequate diversional activity.
Correct Answer: C
Rationale: Alcohol use can contribute to sleep disturbances, including nightmares, making it a critical factor to explore in relation to the client's symptoms.
Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?
- A. Determine the client's reason for attempting suicide.
- B. Obtain the client's serum hydrocodone/acetaminophen level.
- C. Encourage the client to increase fluid intake.
- D. Observe the client for further narcotic effects.
Correct Answer: A
Rationale: Determining the client's reason for attempting suicide is the highest priority to understand underlying issues and plan appropriate interventions to prevent recurrence.
A client who is an alcoholic receives a prescription for disulfiram 500 mg PO daily. Which instruction should the nurse provide to this client?
- A. Take the medication each morning beginning 48 hours after your last drink of alcohol.
- B. Take the medication with at least 8 ounces of water and limit alcohol consumption while taking this medication.
- C. Take the medication at bedtime and avoid consuming any more than one ounce of alcohol daily.
- D. Begin taking the medication immediately and take it daily, regardless of whether or not you drink alcohol.
Correct Answer: A
Rationale: Disulfiram should be taken each morning, starting 48 hours after the last drink to prevent a severe reaction, establishing a clear association between the medication and alcohol avoidance.