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A nurse in an acute care mental health facility is admitting a client who reports feeling depressed, sad, moody, and overly anxious. Which of the following is the nurse’s assessment priority?
- A. Coping abilities
- B. Support systems
- C. Suicide risk
- D. Psychiatric history
Correct Answer: C
Rationale: The correct answer is C: Suicide risk. This is the priority assessment because the client is reporting symptoms of depression and anxiety, which are risk factors for suicide. Assessing suicide risk is crucial for ensuring the client's safety. Coping abilities (A) and support systems (B) are important, but assessing suicide risk takes precedence in this situation. Psychiatric history (D) may provide valuable information, but it is not the priority when the client is actively reporting symptoms of depression and anxiety.
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A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania?
- A. The client's spouse reports that the client has recently gained weight.
- B. The client is dressed in all black.
- C. The client responds to questions with disorganized speech.
- D. The client reports that voices are telling him to write a novel.
Correct Answer: C
Rationale: The correct answer is C because disorganized speech is a key symptom of acute mania in bipolar disorder. Disorganized speech is characterized by incoherent, rapid, and tangential responses, reflecting the racing thoughts and pressured speech commonly seen in manic episodes. This symptom is indicative of a manic state, which is a defining feature of bipolar disorder. Choices A, B, and D are incorrect because they do not directly relate to the diagnostic criteria for acute mania. Weight gain, clothing color choice, and auditory hallucinations are not specific to mania and could be present in other mental health conditions.
A nurse is caring for an adolescent client who has conduct disorder. The client reports that she has received five speeding tickets in the past 6 months. Which of the following interventions should the nurse take?
- A. Make a contract with the client not to drive over the speed limit.
- B. Call the local police and alert them to the client's car license plate number and the make and model of her car.
- C. Ask the client to "hand over the keys" to you and tell her that now she must use a cab or other public transportation until your next session.
- D. Inform the client that she cannot drink and drive.
Correct Answer: A
Rationale: The correct answer is A: Make a contract with the client not to drive over the speed limit. This intervention is appropriate as it establishes clear boundaries and expectations for the client's behavior, addressing the issue of multiple speeding tickets. By creating a contract, the nurse can work with the client to set specific goals and consequences for adhering to the speed limit. This method promotes accountability and helps the client understand the importance of safe driving practices.
Other choices are incorrect:
B: Calling the local police would breach confidentiality and trust, which is not ethical.
C: Taking away the client's keys may be seen as punitive and could lead to resistance or defiance.
D: While important, the issue of drinking and driving is not directly related to the client's speeding tickets.
A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the following actions should the nurse take?
- A. Set limits for the relationship
- B. Promote the use of transference by the client
- C. Instruct the client on how he should behave
- D. Engage in friendly interactions with the client
Correct Answer: A
Rationale: The correct answer is A: Set limits for the relationship. In a therapeutic relationship, setting boundaries and limits is crucial to establish a safe and professional environment. This helps the client understand the expectations and maintain appropriate behavior. By setting limits, the nurse can ensure a therapeutic focus and prevent any potential harm or misunderstandings.
Choice B (Promote the use of transference by the client) is incorrect because encouraging transference can lead to unrealistic expectations and hinder the therapeutic process. Choice C (Instruct the client on how he should behave) is incorrect as it undermines the client's autonomy and may create a power dynamic. Choice D (Engage in friendly interactions with the client) is incorrect as it blurs professional boundaries and may lead to a lack of objectivity.
A nurse is caring for a group of clients. The nurse should recognize that which of the following clients is at risk for a vitamin B deficiency?
- A. A client who takes gabapentin as part of treatment for a seizure disorder.
- B. A client who has asthma.
- C. A client who has chronic alcohol use disorder.
- D. A client who takes heparin to prevent deep vein thrombosis.
Correct Answer: C
Rationale: The correct answer is C: A client who has chronic alcohol use disorder. Chronic alcohol use can lead to malabsorption of essential vitamins, including vitamin B. Alcohol interferes with the absorption and utilization of vitamin B, leading to a deficiency. This can result in various neurological and hematological complications. Clients with chronic alcohol use disorder are at high risk for vitamin B deficiency and should be closely monitored.
Incorrect Choices:
A: Gabapentin is not directly related to vitamin B deficiency.
B: Asthma does not directly increase the risk of vitamin B deficiency.
D: Heparin does not impact vitamin B levels significantly.
A home health care nurse is visiting an older adult client who tells the nurse that she is feeling tired, is unable to shop for groceries, and would like the nurse to shop for her. Shopping and performing personal errands for the client is prohibited in the nurse's job description. Which of the following is an appropriate nursing response?
- A. "I won’t be able to shop for you today because I have to get home to my family."
- B. "I would be happy to do whatever I can to help you."
- C. "What I think you should do is wait for the days when you feel better and do your grocery shopping then."
- D. "Let's look at some other resources to solve this problem."
Correct Answer: D
Rationale: The correct answer is D: "Let's look at some other resources to solve this problem." This response is appropriate because it acknowledges the client's needs while also maintaining professional boundaries. By exploring other resources, such as community services or family support, the nurse can help the client find a more suitable solution.
A: Incorrect. This response is unprofessional and does not address the client's needs.
B: Incorrect. While it shows willingness to help, it does not address the issue of professional boundaries.
C: Incorrect. This response does not offer a practical solution and may not be feasible for the client.
E, F, G: Irrelevant. No information is provided for these options.