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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 is the most appropriate intervention by the RN to address a client with obsessive-compulsive disorder (OCD) who repeatedly checks to see if the door is locked and asks for reassurance?
- A. Set a specific limit on the number of times the client can check the door.
- B. Help the client find an alternative activity to perform.
- C. Provide consistent reassurance that the door is locked.
- D. Ignore the checking behavior and focus on other behaviors.
Correct Answer: A
Rationale: Setting a specific limit on the checking behavior is the most appropriate intervention for a client with OCD who repeatedly checks the door and seeks reassurance. This approach helps the client gradually reduce the compulsive behavior, promotes independence, and supports progress in treatment. Choice B is not the most suitable intervention as it does not directly address the compulsive checking behavior. Choice C, providing consistent reassurance, may reinforce the compulsive behavior and hinder treatment progress. Choice D of ignoring the behavior does not actively assist the client in managing their symptoms and addressing the underlying disorder.
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.
The nurse is completing the admission assessment of an underweight adolescent admitted to the psychiatric unit with a diagnosis of depression. Which finding requires notification to the healthcare provider?
- A. Body mass index of 21
- B. Potassium level of 2.9 mEq/dL
- C. WBC count of 10,000/mm3
- D. Blood pressure of 110/70 mmHg
Correct Answer: B
Rationale: The correct answer is B. A potassium level of 2.9 mEq/dL is critically low and requires immediate notification to the healthcare provider as it indicates a potential electrolyte imbalance, which can lead to serious cardiac arrhythmias and other complications. Choices A, C, and D are within normal ranges or not indicative of immediate life-threatening issues. A body mass index of 21 may be considered normal for some individuals, a WBC count of 10,000/mm3 is slightly elevated but not an urgent concern, and a blood pressure of 110/70 mmHg is within normal limits for an adolescent.
Which client statement suggests that the client is using a defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit?
- A. At least I hit the wall instead of hitting the psychiatric aide.
- B. I am here because the police thought I was doing something wrong.
- C. I want to be here because I know it is the best psychiatric facility.
- D. Don't believe everything my family tells you, I am not crazy.
Correct Answer: A
Rationale: The correct answer is A because the client is projecting their own aggressive tendencies onto the psychiatric aide by suggesting hitting the wall instead of the aide. This statement reflects projection, a defense mechanism where one attributes their unacceptable feelings or impulses to others. Choice B reflects externalization rather than projection, Choice C reflects rationalization, and Choice D reflects denial.
A female client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What should the nurse do first?
- A. Offer the client a safe place to relax before interviewing her.
- B. Ask the client to describe why she is being stalked.
- C. Recommend that the client talk with a social worker.
- D. Assure the client that the healthcare provider will see her today.
Correct Answer: A
Rationale: When a client presents with signs of distress and potential safety concerns, the priority is to provide a safe environment. Offering a safe place to relax can help the client feel secure and ready for further assessment and support. This action allows the nurse to establish rapport, ensure the client's immediate safety, and create a trusting relationship before delving into the details of the situation. Asking the client to describe why she is being stalked (Choice B) may exacerbate her distress and should come after ensuring her safety. Recommending that the client talk with a social worker (Choice C) is important but should follow immediate safety measures. Assuring the client that the healthcare provider will see her today (Choice D) is less critical than addressing her safety concerns and emotional state.