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A nurse in a mental health clinic is assessing a client who was brought in by her adult daughter stating that her mother has not been able to leave her home for weeks because she is afraid to be outdoors alone. The nurse should anticipate planning care for managing which of the following phobias?
- A. Xenophobia
- B. Acrophobia
- C. Mysophobia
- D. Agoraphobia
Correct Answer: D
Rationale: Agoraphobia is the fear of being in open or public spaces, leading to avoidance behavior.
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A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband." Which of the following is a therapeutic nursing response?
- A. "Your husband is making really good progress."
- B. "Crying helps us let things out and we feel better."
- C. "Did your husband say something to upset you?"
- D. "Tell me what’s concerning you."
Correct Answer: D
Rationale: Encouraging the spouse to verbalize concerns supports therapeutic communication.
A nurse is teaching a newly licensed nurse about appropriate actions to take when a client threatens to harm a specific individual. Which of the following statements by the newly licensed nurse indicates understanding?
- A. "I need to make sure that the potential victim is warned."
- B. "I need to keep the information confidential due to the client's right to privacy."
- C. "I can only discuss the client’s threats with a court order."
- D. "I should verbally report this information to the psychiatrist."
Correct Answer: A
Rationale: The correct answer is A. When a client threatens harm to a specific individual, the appropriate action is to ensure the safety of the potential victim by warning them. This is crucial in preventing harm and fulfilling the nurse's duty to protect life. Option B is incorrect because in cases of potential harm, confidentiality can be breached to protect others. Option C is incorrect as waiting for a court order delays necessary action. Option D is incorrect as immediate action should be taken rather than waiting for a psychiatrist's involvement.
A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for the client?
- A. A private room in a quiet location on the unit
- B. A semiprivate room with a roommate who has similar symptoms
- C. A private room close to the nursing station
- D. A seclusion room until the client's activity level becomes more subdued
Correct Answer: C
Rationale: The correct answer is C: A private room close to the nursing station. This choice ensures the client's safety and allows for close monitoring by the nursing staff due to the increased risk of impulsive behaviors during the manic phase. A private room helps minimize distractions and stimuli that can exacerbate manic symptoms, while proximity to the nursing station enables quick intervention if needed.
Incorrect choices:
A: A private room in a quiet location on the unit - While privacy is important, a quiet location may not provide adequate supervision and support for a client in the manic phase.
B: A semiprivate room with a roommate who has similar symptoms - Sharing a room with someone exhibiting similar symptoms may lead to escalation of behaviors and lack of supervision.
D: A seclusion room until the client's activity level becomes more subdued - Seclusion should only be used as a last resort for safety concerns and is not appropriate for managing manic symptoms.
A nurse in an emergency department is caring for a client who is experiencing acute alcohol withdrawal. Which of the following actions should the nurse take first?
- A. Implement seizure precautions.
- B. Insert an IV access site.
- C. Obtain a blood specimen.
Correct Answer: A
Rationale: The correct answer is A: Implement seizure precautions. The priority in caring for a client experiencing acute alcohol withdrawal is to prevent potential life-threatening complications like seizures. Implementing seizure precautions involves ensuring a safe environment, such as padding the bed and removing any harmful objects. This step takes precedence over inserting an IV access site (B) or obtaining a blood specimen (C) because seizures pose an immediate risk to the client's safety. It is crucial to address the most urgent need first to ensure the client's well-being.
A nurse manager is providing staff education about working with clients who have a history of anger and aggression. Which of the following information should the nurse include in the teaching? (Select all that apply.)
- A. Avoid wearing necklaces during client care.
- B. Know the layout of the facility.
- C. Stand directly in front of the client when talking.
- D. Bring security with you for all client interactions.
- E. Provide immediate verbal feedback for escalating behavior.
Correct Answer: A, B, E
Rationale: The correct answers are A, B, and E. A: Wearing necklaces can be used as a weapon or trigger aggressive behavior. B: Knowing the facility layout helps in planning safe exits during an escalating situation. E: Providing immediate verbal feedback can help de-escalate aggressive behavior. C: Standing directly in front of the client can be confrontational. D: Bringing security for all interactions may escalate tension unnecessarily.