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A nurse in a mental health facility is caring for a client who has borderline personality disorder. Which of the following findings should the nurse expect?
- A. Persistent mood swings
- B. Hypersomnia
- C. Avoidance of eye contact
- D. Ritualistic behaviors
Correct Answer: A
Rationale: The correct answer is A: Persistent mood swings. Borderline personality disorder is characterized by unstable emotions, leading to frequent and intense mood swings. This is a hallmark feature of the disorder. Hypersomnia (choice B) is not typically associated with borderline personality disorder. Avoidance of eye contact (choice C) is more commonly seen in conditions like social anxiety disorder. Ritualistic behaviors (choice D) are more characteristic of obsessive-compulsive disorder, not borderline personality disorder. In summary, persistent mood swings are a key feature of borderline personality disorder, distinguishing it from the other options provided.
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A nurse is caring for a client with Alzheimer’s disease. Which of the following actions should the nurse take?
- A. Seat the client at a dining table with six or more residents
- B. Provide the client with several choices for meal selection
- C. Give complete directions before starting client care
- D. Use symbols to assist the client in locating rooms
Correct Answer: D
Rationale: The correct answer is D. Using symbols to assist the client in locating rooms is beneficial for a client with Alzheimer's as they may have difficulty remembering locations. Symbols can serve as visual cues to help them navigate and reduce confusion. A: Seating the client at a dining table with multiple residents may be overwhelming and lead to agitation. B: Providing several meal choices can be confusing and increase indecision for someone with Alzheimer's. C: Giving complete directions all at once may be too much information for the client to process. Instead, simple and clear instructions are more effective.
A nursing is advising an assistive personnel (AP) on the care of a client who has major depressive disorder. The AP states that he is irritated by the client’s depression. Which of the following statements by the nurse is appropriate?
- A. Please don’t take what the client said seriously when she is depressed
- B. It’s important that the client feel safe verbalizing how she is feeling
- C. Everybody feels that way about this client so don’t worry about it
- D. I’ll change your assignment to someone who doesn’t have depressive disorder
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Changing the AP's assignment is appropriate because it addresses the issue of the AP's irritation towards the client's depression. It ensures the client's care is not compromised and maintains a supportive environment. This action also prevents negative attitudes from affecting the client's well-being.
Summary of other choices:
A: Incorrect. Minimizing the client's feelings is inappropriate and may invalidate their experiences.
B: Incorrect. While it is important for the client to verbalize feelings, the focus here is on addressing the AP's behavior.
C: Incorrect. Dismissing the AP's feelings and normalizing negative attitudes are not appropriate responses.
E, F, G: Not provided, but based on the context, they are likely to be irrelevant or inappropriate responses.
A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?
- A. Rationalization
- B. Denial
- C. Compensation
- D. Displacement
Correct Answer: C
Rationale: The client is demonstrating the defense mechanism of Compensation. Compensation involves covering up weaknesses by emphasizing strengths in other areas. In this scenario, the client is compensating for feeling inadequate or unappreciated by becoming angry and defensive when his actions are questioned. This behavior serves to divert attention away from his perceived shortcomings and protect his self-esteem.
Rationalization (A) involves creating logical explanations to justify behaviors or feelings. Denial (B) is refusing to acknowledge unpleasant realities. Displacement (D) is redirecting emotions from the real target to a substitute target. In this case, these defense mechanisms are not as applicable as Compensation, which directly relates to the client's behavior of overcompensating for his perceived lack of attention.
A nurse is providing teaching to a client who has panic disorder and is receiving alprazolam. Which of the following instructions should the nurse include?
- A. Take the medication on an empty stomach
- B. Avoid activities that require alertness
- C. Stop taking the medication if dizziness occurs
- D. Take an additional dose if anxiety increases
Correct Answer: B
Rationale: The correct answer is B: Avoid activities that require alertness. This is important because alprazolam is a benzodiazepine that can cause drowsiness and impair cognitive function. By avoiding activities that require alertness, the client can prevent accidents or injuries.
A: Taking the medication on an empty stomach is not necessary for alprazolam.
C: Stopping the medication if dizziness occurs is not recommended without consulting a healthcare provider.
D: Taking an additional dose if anxiety increases can lead to overdose and is not safe.
Therefore, choice B is the most appropriate instruction to include in teaching the client with panic disorder taking alprazolam.
A nurse is caring for a client who has schizophrenia and takes clozapine. Which of the following findings is a priority for the nurse to report to the provider?
- A. Nausea
- B. Random blood glucose 130 mg/dL
- C. Heart rate 104 per minute
- D. Sore throat
Correct Answer: D
Rationale: The correct answer is D: Sore throat. A priority finding to report with clozapine is agranulocytosis, which presents with symptoms like sore throat. This is crucial to detect early to prevent severe infection. A: Nausea is a common side effect of clozapine but not a priority over potential agranulocytosis. B: Random blood glucose of 130 mg/dL is slightly elevated but not an immediate concern. C: Heart rate of 104 per minute may be a side effect but is not as critical as agranulocytosis. Reporting the sore throat promptly can lead to timely intervention and prevent serious complications.