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A male employee who is assessed weekly in the employee clinic for blood pressure because of a history of hypertension tells the nurse that he is so upset with one of his co-workers that he would like to shoot him. What action should the nurse take first?
- A. Determine if the client has a weapon available for use.
- B. Inform the health care provider of the threat to harm a co-worker.
- C. Notify security of the client's intention to harm a co-worker.
- D. Have the employee escorted to a mental health facility.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The client is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing diagnosis for discharge planning?
- A. Ineffective denial related to situational anxiety.
- B. Ineffective coping related to inadequate support.
- C. Social isolation related to difficult interactions.
- D. Self-care deficit related to cognitive impairment.
Correct Answer: A
Rationale: The best nursing diagnosis is (A) because the client is unable to acknowledge the move to a boarding home. While (B, C, and D) are potential nursing diagnoses, denial is the most critical as it is a defense mechanism preventing the client from addressing his feelings regarding the change in living arrangements.
The nurse suspects child abuse when assessing a 3-year-old boy and noticing several small, round burns on his legs and trunk that might be the result of cigarette burns. Which parental behavior provides the greatest validation for such suspicions?
- A. The parents' explanation of how the burns occurred is different from the child's explanation of how they occurred.
- B. The parents seem to dismiss the severity of the child's burns, saying they are very small and have not posed any problem.
- C. The parents become very anxious when the nurse suggests that the child may need to be admitted for further evaluation.
- D. The parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's observation of the type of burn.
Correct Answer: D
Rationale: (D) provides the most validation for suspecting child abuse. The parent's explanation (subjective data) that the child was burned in a house fire is incompatible with the objective data observed by the nurse (small, round burns on the legs and trunk). (A) relies on subjective data, and the child's explanation might not accurately reflect the situation due to various factors like age or fear. The apparent lack of concern from the parents (B) is inconclusive as the nurse's interpretation of their reaction could be subjective. While parental anxiety (C) could hint at potential child abuse, it's important to note that most parents would naturally be anxious about their child's hospitalization, making it a less definitive indicator compared to the inconsistency in the explanation provided by the parents in option (D).
The LPN/LVN is caring for a client with schizophrenia who is experiencing auditory hallucinations. Which intervention is most appropriate?
- A. Encourage the client to focus on reality-based activities.
- B. Ask the client to describe the voices he hears.
- C. Tell the client that the voices are not real.
- D. Encourage the client to interact with others who are not experiencing hallucinations.
Correct Answer: B
Rationale: Asking the client to describe the voices he hears is the most appropriate intervention in this situation. It helps the nurse assess the content and severity of the hallucinations, enabling the planning of appropriate interventions. Choice A is not as effective as directly addressing the hallucinations. Choice C may lead to mistrust as the client believes the voices are real. Choice D does not address the client's immediate need related to the hallucinations.
A client is admitted to the psychiatric unit with a diagnosis of bipolar disorder, manic phase. Which activity is most appropriate for the LPN/LVN to suggest to the client?
- A. Playing a game of basketball with other clients.
- B. Taking a walk with the nurse in the garden.
- C. Working on a puzzle in a quiet room.
- D. Writing in a journal.
Correct Answer: C
Rationale: During the manic phase of bipolar disorder, individuals may experience heightened levels of energy and agitation. Engaging in activities that are overly stimulating, such as playing basketball with others (choice A) or taking a walk in a garden (choice B), can exacerbate these symptoms. Writing in a journal (choice D) may also be too stimulating and may not provide the necessary distraction. Working on a puzzle in a quiet room (choice C) can offer a calming and focused activity that helps reduce anxiety and channel excess energy into a structured task, making it the most appropriate choice for a client in the manic phase of bipolar disorder.
A 27-year-old female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. She is demanding and active. Which intervention should the nurse include in this client's plan of care?
- A. Schedule noncompetitive activities that can be carried out alone.
- B. Monitor her decision-making process.
- C. Encourage her to identify feelings of anger.
- D. Provide a structured environment with little stimuli.
Correct Answer: D
Rationale: Clients in the manic phase of bipolar disorder require a structured environment with decreased stimuli to help manage their symptoms. Providing a structured environment with little stimuli (D) can help reduce the risk of escalating behaviors. Scheduling noncompetitive activities that can be carried out alone (A) is more appropriate than group activities as excessive stimuli should be avoided. Monitoring decision-making processes (B) is important due to impulsivity in manic phases. Encouraging the client to identify feelings of anger (C) is not the priority in managing manic symptoms, as it is more often associated with depression than bipolar disorder.