Nokea
A nurse in a mental health facility is caring for a client who has antisocial personality disorder and alcohol dependency. The nurse should encourage the client to participate in which of the following groups?
- A. Codependency support.
- B. Psychodrama.
- C. Dual diagnosis treatment.
- D. Behavioral therapy.
Correct Answer: C
Rationale: Dual diagnosis treatment is specifically designed to address the simultaneous presence of a mental health disorder and substance use disorder. It provides an integrated approach to treatment that addresses both conditions simultaneously, fitting the client’s needs.
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A nurse is caring for a client who has depression and reports only sleeping a few hours each night. Which of the following instructions should the nurse give the client to promote sleep?
- A. You should drink a glass of wine 1 hour before you go to bed.
- B. You should eat a meal just prior to bedtime.
- C. You should take a nap after lunch.
- D. You should limit yourself to two caffeinated beverages per day.
Correct Answer: D
Rationale: Limiting caffeine intake to two beverages per day can promote better sleep. Caffeine is a stimulant that can interfere with falling asleep and staying asleep, especially if consumed later in the day. This instruction supports improved sleep quality.
A nurse is caring for a newly admitted client who has obsessive-compulsive disorder. Which of the following actions should the nurse take first?
- A. Discuss the benefits of relaxation exercises with the client.
- B. Explain the use of response prevention to the client.
- C. Administer an antianxiety medication.
- D. Calculate the client's score on the Hamilton Rating Scale for Anxiety.
Correct Answer: D
Rationale: Calculating the Hamilton Rating Scale for Anxiety provides an initial assessment of the client's anxiety severity, guiding further interventions. This baseline data collection is the priority upon admission to tailor subsequent care.
A nurse is participating in a community program about eating disorders. Which of the following information about bulimia nervosa should the nurse include in the presentation?
- A. People who have bulimia nervosa are at risk for developing diabetes mellitus.
- B. Bulimia nervosa is difficult to notice because a person might be of average or ideal body weight.
- C. People who have bulimia nervosa eat an average amount of food on a daily basis.
- D. As long as a person is not vomiting after eating, they do not have bulimia nervosa.
Correct Answer: B
Rationale: Individuals with bulimia nervosa often maintain an average or ideal body weight, making the disorder less visible. This highlights a key characteristic for community education.
A nurse is reinforcing teaching with the caregiver of a client who has Alzheimer's disease. The caregiver reports that the client awakens at night and wanders. Which of the following strategies should the nurse suggest?
- A. Place a lock at the top of doors leading outside.
- B. Use light restraints while the client is in bed.
- C. Administer an antianxiety medication before bedtime.
- D. Encourage the client to nap during the day.
Correct Answer: A
Rationale: Placing a lock at the top of doors helps prevent the client from wandering outside, ensuring safety. This is a practical, non-restrictive measure to manage nighttime wandering in Alzheimer’s.
A nurse is collecting data from a client who has schizophrenia. Which of the following client statements indicates that the client is experiencing a command hallucination?
- A. Can you see these spiders crawling all over me?
- B. The aliens are going to abduct me tonight.
- C. Are you planning to kill me?
- D. The voices told me to quit eating the food here.
Correct Answer: D
Rationale: The statement 'The voices told me to quit eating the food here' is indicative of a command hallucination, where the client hears voices instructing them to take specific actions. This distinguishes it from visual hallucinations or delusions.