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A male client with schizophrenia continues to talk to others on the mental health unit using tangential speech. What intervention should the nurse implement?
- A. Tell the client to discuss his ideas with others when his thoughts are more clear.
- B. Teach the client to slow down and focus on the topic by listening to his words.
- C. Ask the client to repeat his comments.
- D. Confront the client when he talks rapidly.
Correct Answer: B
Rationale: Teaching the client to slow down and focus on the topic by listening to his words is a therapeutic intervention to address tangential speech and improve communication.
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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.
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.
A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the nurse implement first?
- A. Show the client the unit.
- B. Explain the nurse's role to the client.
- C. Read the client his/her rights.
- D. Offer medication to the client.
Correct Answer: B
Rationale: Explaining the nurse's role helps establish trust and provides the client with information about who is present and their purpose, facilitating initial communication.
A female client with obsessive-compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the nurse at bedtime. What action should the nurse implement?
- A. Explain to the client that her behavior invades the rights of the nursing staff.
- B. Teach the client strategies to control her obsessive-compulsive behavior.
- C. Ask the client to explain why she is keeping a detailed record of her nursing care.
- D. Encourage the client to express her feelings regarding the upcoming procedure.
Correct Answer: D
Rationale: Encouraging the client to express feelings regarding the upcoming procedure addresses potential anxiety driving the behavior, offering a therapeutic approach.
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.