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A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement?
- A. Isolate the client from the other clients.
- B. Administer PRN sedative.
- C. Avoid recognizing the behavior.
- D. Escort the client to his room.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The client is being educated by the healthcare provider about starting a prescribed abstinence therapy with disulfiram (Antabuse). What information should the client understand?
- A. Maintain complete abstinence from heroin or cocaine use.
- B. Stay alcohol-free for at least 12 hours before the first dose.
- C. Participate in monthly Alcoholics Anonymous meetings.
- D. Disclose to others that he is a substance abuser.
Correct Answer: B
Rationale: The correct answer is B. Before starting disulfiram therapy (Antabuse), the client must comprehend the need to remain alcohol-free for a minimum of 12 hours. This is crucial to prevent the unpleasant and potentially dangerous reactions that can occur with concurrent alcohol consumption while on disulfiram. Choices A, C, and D are incorrect because they do not directly relate to the specific requirement for alcohol abstinence before initiating disulfiram therapy.
An adolescent with a history of bipolar disorder is hospitalized during a manic episode. Which intervention is most appropriate for the nurse to include in the care plan?
- A. Encourage high levels of physical activity.
- B. Provide a quiet and structured environment.
- C. Engage the client in creative arts activities.
- D. Allow the client to make decisions about their schedule.
Correct Answer: B
Rationale: During a manic episode, individuals with bipolar disorder may experience heightened energy levels, decreased need for sleep, and racing thoughts. Providing a quiet and structured environment is crucial in managing these symptoms as it helps reduce external stimuli, prevent overstimulation, and promote a sense of calmness. Encouraging high levels of physical activity may exacerbate the manic symptoms by further increasing stimulation and excitement. Engaging the client in creative arts activities might be beneficial during stable periods but may not be the most appropriate intervention during a manic episode. Allowing the client to make decisions about their schedule could potentially lead to impulsivity and poor judgment, which are common characteristics of mania.
A client is agitated and physically aggressive. What action should the RN take first?
- A. Calmly inform the client that they will be placed in seclusion if they do not calm down.
- B. Discuss with the client the reasons for their agitation and aggression.
- C. Tell the client that physical aggression is not acceptable and must stop.
- D. Seek assistance from other staff members and follow the facility's protocol.
Correct Answer: D
Rationale: In a situation where a client is agitated and physically aggressive, the priority for the RN is to ensure the safety of the client and others. Seeking assistance from other staff members is crucial as it allows for a prompt response to manage the situation effectively and according to the facility's protocol. Choices A, B, and C do not address the immediate need for safety or involve the collaboration of other staff members, which is essential in handling aggressive behaviors in a healthcare setting.
What intervention is best for the nurse to implement for a male client with schizophrenia who is demonstrating echolalia, which is becoming annoying to other clients on the unit?
- A. Avoid recognizing the behavior.
- B. Isolate the client from other clients.
- C. Administer a PRN sedative.
- D. Escort the client to his room.
Correct Answer: D
Rationale: Echolalia, the constant repetition of what others are saying, can be disruptive to the therapeutic environment. The most appropriate intervention is to escort the client to his room. This action provides the client with a private space where he can engage in the behavior without disturbing other clients. Avoiding recognition of the behavior (Choice A) may not address the issue and could lead to increased annoyance among other clients. Isolating the client (Choice B) may have negative psychological effects and should be avoided unless absolutely necessary for safety concerns. Administering a PRN sedative (Choice C) should be considered only as a last resort and if other de-escalation techniques have been unsuccessful.
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 action is most important for the nurse to take?
- A. Assure the client that the healthcare provider will see her today.
- B. Recommend that the client talk with a social worker.
- C. Ask the client to describe why she is being stalked.
- D. Offer the client a safe place to relax before interviewing her.
Correct Answer: D
Rationale: The most important action for the nurse to take in this scenario is to offer the client a safe place to relax before interviewing her. The client's disheveled appearance and foul body odor suggest she may be in distress or facing challenging circumstances. By providing her with a safe and comfortable environment to relax, the nurse can help alleviate some of her distress and establish trust. This approach is crucial as the client is already feeling scared due to being stalked, indicating underlying mental health concerns. Assuring the client of a healthcare provider visit (choice A) may not address her immediate need for safety and comfort. Recommending she talk with a social worker (choice B) may be beneficial later but does not address the immediate need for a safe space. Asking the client to describe why she is being stalked (choice C) is not appropriate as the priority is ensuring her safety and comfort first.