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A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN?
- A. Is attempting the physically restrain the patient.
- B. Remains at a distance of 4 feet from the client.
- C. Tells the client to go to the quiet area of the unit.
- D. Is using a loud voice to talk to the client.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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After receiving treatment for anorexia, a student asks the school nurse for permission to work in the school cafeteria as part of the school's work-study program. What action should the nurse take?
- A. Recommend assignment to the receptionist's office.
- B. Suggest that the student work in the athletic department.
- C. Refer the student to a psychiatrist for further discussion.
- D. Determine the parents' opinion of the work assignment.
Correct Answer: A
Rationale: Clients with anorexia are often fixated on food and exercise, which can exacerbate their condition. By recommending assignment to the receptionist's office, the nurse provides an environment that minimizes exposure to food-related triggers. Working in the cafeteria may intensify the student's preoccupation with food, making it an unsuitable choice. Referring the student to a psychiatrist without exploring less triggering work options first may not be necessary. Determining the parents' opinion is important, but in this context, the focus should be on selecting a work environment that supports the student's recovery.
A client with schizophrenia is being discharged home after an extended stay in a psychiatric hospital. Which statement by the client indicates that further teaching about medication management is needed?
- A. "I will take my medication only when I feel like it."
- B. "I need to follow up with my psychiatrist regularly."
- C. "I will notify my healthcare provider if I experience side effects."
- D. "I should avoid alcohol while on my medication."
Correct Answer: A
Rationale: The correct answer is A. This statement indicates a lack of understanding about medication management for schizophrenia. Medications for schizophrenia should be taken consistently as prescribed for optimal effectiveness, regardless of how the client feels. Choice B is a correct statement as regular follow-up with a psychiatrist is important for monitoring progress and adjusting treatment. Choice C demonstrates good awareness of potential side effects and the need for communication with healthcare providers. Choice D reflects appropriate knowledge as alcohol can interact with medications and may reduce their effectiveness.
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.
The occupational health nurse is working with a female employee who was just notified that her child was involved in a MVA and taken to the hospital. The employee states, "I can't believe this. What should I do?" Which response is best for the nurse to provide in this crisis?
- A. Tell me what you think should be done.
- B. How serious was the collision?
- C. What do you think you should do?
- D. Call for transportation to the hospital.
Correct Answer: D
Rationale: In a crisis situation where the female employee's child is involved in a motor vehicle accident (MVA) and taken to the hospital, the most appropriate response for the nurse is to provide immediate practical assistance. Calling for transportation to the hospital ensures that the employee can quickly reach her child in need of urgent medical attention. The other options (A, B, and C) do not address the immediate need for assistance and may not provide the necessary support required in such a critical situation.
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.