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A nurse has admitted a client to the mental health unit following an attempted suicide. The client also attempted suicide four months earlier. Which is the best way to ensure client safety?
- A. give the client a task to do, such as folding towels, to distract him
- B. assign a staff member to remain with the client one-on-one at all times
- C. obtain an order for chemical and physical restraints to be used as needed
- D. keep the client in the day room around other clients who can help watch the client
- E. place the client in isolation after removing potentially unsafe articles, such as shoelaces and belts
Correct Answer: B
Rationale: One-on-one supervision is the most effective way to ensure safety for a client with recent suicide attempts, as it allows immediate intervention if needed.
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A client has been diagnosed with terminal cancer and is using opioid analgesics for pain relief. Which action by the home care nurse would best allay the client's anxiety about becoming addicted to the pain medication?
- A. Encouraging the client to hold off as long as possible between doses of pain medication
- B. Encouraging the client to take lower doses of medications even though the pain is not well controlled
- C. Explaining to the client that the fears are justified but should be of no concern during the final stages of care
- D. Explaining to the client that addiction rarely occurs in individuals who are taking medication appropriately to relieve pain
Correct Answer: D
Rationale: Clients who are on opioid analgesics often have well-founded fears about addiction, even in the face of pain. The nurse has the responsibility to provide correct information about the likelihood of addiction while still maintaining adequate pain control. Addiction is rare for individuals who are taking medication to relieve pain. Allowing the client to be in pain, as in options 1 and 2, is not acceptable nursing practice. Option 3 is only partially correct in that it acknowledges the client's fear.
A client diagnosed with an obsessive-compulsive disorder spends many hours during the day and night washing hands. The nurse should initially allow the client to continue this behavior because it has what therapeutic effect for the client?
- A. Relieves the client's anxiety
- B. Decreases the chance of infection
- C. Gives the client a feeling of self-control
- D. Increases the client's sense of self-esteem
Correct Answer: A
Rationale: The compulsive act provides immediate relief from anxiety and is used to cope with stress, conflict, or pain. Options 2 and 3 are also incorrect interpretations of the client's need to perform this behavior. Although the client may feel the need to increase self-esteem, that is not the primary goal of this behavior.
The nurse is interviewing a client being admitted to the mental health inpatient unit who was involved in a fire 2 months ago. The client is reporting insomnia, difficulty concentrating, nervousness, hypervigilance, and frequently thinking about fires. The nurse should recognize these complaints to be indications of which disorder?
- A. Phobia
- B. Dissociative disorder
- C. Obsessive-compulsive disorder
- D. Post-traumatic stress disorder (PTSD)
Correct Answer: D
Rationale: PTSD is precipitated by events that are overwhelming, unpredictable, and sometimes life threatening. Typical symptoms of PTSD include difficulty concentrating, sleep disturbances, intrusive recollections of the traumatic event, hypervigilance, and anxiety. These symptoms are not characteristic of the disorders noted in options 1, 2, and 3.
The mental health nurse is caring for a client with Cluster B personality disorder. The nurse would expect the client to exhibit which behaviors? Select all that apply.
- A. suspicious of others, magical thinking, eccentric behavior, paranoia, relationship deficits
- B. preoccupation with rules and details, hoarding, ritualistic behavior, extremely devoted to work
- C. easily bored, poor and shallow interpersonal relationships, enjoys being the center of attention
- D. impulsivity, unpredictable behavior, extreme mood shifts, easily angered, playing people against each other
- E. suspicious and untrusting of others, argumentative, controlling of others, thoughts of grandiosity
Correct Answer: C,D
Rationale: Cluster B personality disorders (e.g., histrionic, borderline) involve attention-seeking, shallow relationships, impulsivity, and mood instability. Options A and E describe Cluster A, and B describes Cluster C.
The nurse is caring for an older client who has been placed in Buck's extension traction after a hip fracture. During the assessment of the client, the nurse notes that the client is disoriented. Which is the most appropriate nursing intervention for this client?
- A. Apply restraints to the client.
- B. Ask the family to stay with the client.
- C. Ask the laboratory to perform electrolyte studies.
- D. Reorient the client to time, place, and person frequently.
Correct Answer: D
Rationale: An inactive older person may become disoriented as a result of a lack of sensory stimulation. The appropriate nursing intervention would be to frequently reorient the client and place objects such as a clock and a calendar in the client's room to maintain orientation. Restraints may cause further disorientation and should not be applied unless specifically prescribed. Agency policies and procedures should be followed before the application of restraints. The family can assist with the orientation of the client, but it is not appropriate to ask the family to stay with the client. It is not within the scope of nursing practice to prescribe laboratory studies.