A male client with schizophrenia is being discharged from the psychiatric unit after being stabilized with antipsychotic medications. What is the most important instruction to include in the discharge teaching?
- A. "You should see your psychiatrist every 6 months."
- B. "It's important to adhere to the medication regimen as prescribed."
- C. "Try to avoid caffeine and alcohol completely."
- D. "You should exercise daily to maintain a healthy lifestyle."
Correct Answer: B
Rationale: The most important instruction to include in the discharge teaching for a male client with schizophrenia who has been stabilized with antipsychotic medications is to adhere to the medication regimen as prescribed. Medication adherence is crucial in managing schizophrenia, preventing relapse, and maintaining stability. While seeing the psychiatrist regularly (Choice A) is important, adherence to medication is more critical for the client's immediate well-being. Avoiding caffeine and alcohol (Choice C) may be beneficial but is not as crucial as medication adherence. Daily exercise (Choice D) is important for overall health but is not the most critical instruction for managing schizophrenia.
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What principle about patient-nurse communication should guide a nurse's fear of 'saying the wrong thing' to a patient?
- A. Patients tend to appreciate a well-meaning person who conveys genuine acceptance, respect, and concern for their situation.
- B. The patient is more interested in talking to you than listening to what you have to say and is not likely to be offended.
- C. Considering the patient's history, there is little chance that the comment will do any actual harm.
- D. Most people with a mental illness have by necessity developed a high tolerance for forgiveness.
Correct Answer: A
Rationale: The correct principle guiding nurse-patient communication is that patients value genuine acceptance, respect, and concern. Choice A is the correct answer because showing genuine care and concern for the patient's situation fosters a positive and therapeutic relationship. Choice B is incorrect as effective communication involves active listening and responding appropriately, not assuming the patient is only interested in talking. Choice C is incorrect because a patient's history does not guarantee immunity to harm from inappropriate comments. Choice D is incorrect as it generalizes individuals with mental illness and forgiveness, which is not directly related to communication fears.
A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?
- A. Place in a side-lying position with head of bed elevated.
- B. Administer disulfiram (Antabuse) immediately
- C. Give lorazepam (Ativan) PRN for signs of withdrawal.
- D. Provide thiamine and folate supplements as prescribed.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and lack of motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?
- A. Provide education on methods to enhance sleep.
- B. Teach the client to develop a plan for daily structured activities.
- C. Suggest that the client develop a list of pleasurable activities.
- D. Encourage the client to exercise.
Correct Answer: B
Rationale: Teaching the client to develop a plan for daily structured activities is the most effective intervention in this scenario. This intervention helps address psychomotor retardation and enhances motivation and functioning. By structuring the client's day, it can provide a sense of purpose, routine, and accomplishment. Option A, providing education on methods to enhance sleep, may be helpful but does not directly address the client's overall functioning. Option C, suggesting the client develop a list of pleasurable activities, may provide temporary relief but may not address the core symptoms of major depressive disorder. Option D, encouraging the client to exercise, can be beneficial, but in this case, addressing the lack of structure and motivation through a daily plan is more appropriate.
A client with schizophrenia is exhibiting visual and auditory hallucinations. What should be the RN's initial intervention?
- A. Instruct the client to ignore the hallucinations.
- B. Encourage the client to describe the hallucinations in detail.
- C. Assess the client's perception of the hallucinations.
- D. Provide reassurance that the hallucinations are not real.
Correct Answer: C
Rationale: The correct initial intervention for a client with schizophrenia exhibiting visual and auditory hallucinations is to assess the client's perception of the hallucinations. This step is crucial as it helps the RN determine the severity of the hallucinations and the best course of action for management and intervention. Instructing the client to ignore the hallucinations (Choice A) may not be effective as the hallucinations may be distressing and overwhelming. Encouraging the client to describe the hallucinations in detail (Choice B) may potentially worsen the symptoms or trigger further distress. Providing reassurance that the hallucinations are not real (Choice D) may not be appropriate as the client may genuinely believe in their reality, and this reassurance may not address the underlying issues causing the hallucinations.
While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-taking during an interview?
- A. The client's comfort level is increased when the nurse maintains eye contact while taking notes.
- B. The interview process is enhanced with note-taking, allowing the client to speak at a normal pace.
- C. Note-taking during an interview is not a legal obligation of the examining nurse.
- D. The nurse's ability to directly observe the client's nonverbal communication is limited with note-taking.
Correct Answer: D
Rationale: During an interview, note-taking can hinder the nurse's ability to directly observe the client's nonverbal cues such as body language, facial expressions, and tone of voice. These nonverbal cues are crucial for understanding the client's emotions, feelings, and overall communication. Therefore, it is essential for the nurse to strike a balance between note-taking for documentation purposes and actively observing the client's nonverbal communication to ensure a comprehensive assessment. Choices A, B, and C are incorrect because maintaining eye contact, enhancing the interview process with note-taking, and legal obligations of note-taking during an interview do not directly address the issue of limited observation of nonverbal communication while taking notes.