Nokea
A nurse in an acute care mental health facility is placing a client in seclusion and restraints. Which of the following actions should the nurse plan to take?
- A. Ensure that the prescription for restraints be renewed every 6 hr.
- B. Document the client's behavior every 15 min.
- C. Request a provider to evaluate the client in person every 36 hr.
- D. Plan to monitor the client every 30 min while restrained.
Correct Answer: B
Rationale: The correct answer is B: Document the client's behavior every 15 min. This action is important to ensure the client's safety and monitor their response to seclusion and restraints. Documenting behavior every 15 minutes allows the nurse to track changes, identify any signs of distress, and ensure the client's well-being. It also helps in providing a detailed record of the client's condition for further evaluation and decision-making.
The other choices are incorrect because:
A: Ensuring the prescription for restraints be renewed every 6 hr is not necessary for immediate monitoring and safety.
C: Requesting a provider to evaluate the client in person every 36 hr is not frequent enough for close monitoring and intervention.
D: Planning to monitor the client every 30 min while restrained is not as frequent as every 15 minutes, which may miss important changes in behavior or condition.
You may also like to solve these questions
A nurse is caring for a client with major depressive disorder who has a new prescription for fluoxetine. Which statement by the client indicates an understanding of the medication?
- A. I should expect to see improvement in my mood within a few days.
- B. I may experience increased thoughts of suicide at the beginning of treatment.
- C. I need to avoid foods high in tyramine while taking this medication.
- D. I will need to have my lithium levels checked regularly.
Correct Answer: B
Rationale: The correct answer is B: "I may experience increased thoughts of suicide at the beginning of treatment." This statement indicates an understanding of the medication because fluoxetine, an SSRI, can initially increase suicidal ideation in clients with major depressive disorder due to sudden improvement in energy levels before mood improvement. This is important for the client to know for safety monitoring.
Choice A is incorrect as improvement in mood may take several weeks, not days. Choice C is incorrect as avoiding tyramine-rich foods is relevant for MAOIs, not SSRIs like fluoxetine. Choice D is incorrect as lithium levels are monitored for clients taking lithium, not fluoxetine.
A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan?
- A. Place the client in seclusion when he exhibits signs of anxiety.
- B. Encourage the client to spend time in the dayroom.
- C. Withdraw the client's TV privileges if he does not attend group therapy.
- D. Encourage the client to take frequent rest periods.
Correct Answer: D
Rationale: The correct answer is D: Encourage the client to take frequent rest periods. During mania, clients with bipolar disorder may experience heightened energy levels and decreased need for sleep. Encouraging rest periods can help regulate energy levels and promote better sleep patterns, which are crucial in managing manic episodes. Placing the client in seclusion when anxious (choice A) can increase feelings of isolation and worsen symptoms. Encouraging the client to spend time in the dayroom (choice B) may not address the need for rest. Withdrawing TV privileges (choice C) may not directly address the client's manic symptoms.
A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?
- A. I can continue to take St. John's wort while taking this medication.
- B. I know it will be a couple of weeks before the medication helps me feel better.
- C. I expect this medication to raise my blood pressure.
- D. I should take this medication on an empty stomach.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
- Choice B indicates an understanding of the delayed onset of action of amitriptyline, which typically takes a couple of weeks to produce therapeutic effects.
- This knowledge is crucial for managing client expectations and adherence to treatment.
- Choices A, C, and D are incorrect:
- A: Taking St. John's wort with amitriptyline can result in serotonin syndrome due to potential drug interactions.
- C: Amitriptyline can actually lower blood pressure, not raise it.
- D: Amitriptyline is usually taken with food to minimize gastrointestinal side effects.
- In summary, choice B reflects the correct understanding of the medication's timeline for efficacy, while the other choices demonstrate misconceptions or potential risks.
A nurse is providing discharge teaching to a client who has bipolar disorder and a new prescription for lithium. Which statement by the client indicates an understanding of the teaching?
- A. I will reduce my sodium intake to help lithium work better
- B. I should take my medication on an empty stomach
- C. I need to drink 2-3 liters of water each day
- D. I can stop taking lithium once my symptoms improve
Correct Answer: C
Rationale: The correct answer is C: "I need to drink 2-3 liters of water each day." This statement indicates an understanding of the teaching because lithium can cause dehydration and increase the risk of toxicity. Adequate hydration helps to prevent this. Choice A is incorrect because reducing sodium intake is not directly related to lithium's effectiveness. Choice B is incorrect as lithium should be taken with food to reduce gastrointestinal side effects. Choice D is incorrect because stopping lithium abruptly can lead to a relapse of symptoms.
A nurse is admitting a client who has dementia to a long-term care facility. The client tells the nurse that she lived in this facility years ago and took care of all the residents by herself. The nurse should document this as which of the following findings?
- A. Projection
- B. Perseveration
- C. Agnosia
- D. Confabulation
Correct Answer: D
Rationale: The correct answer is D: Confabulation. Confabulation is the creation of false memories to fill in gaps in memory due to brain dysfunction. In this scenario, the client with dementia is creating a false memory about living in the facility and taking care of all the residents by herself. This is a common phenomenon in individuals with dementia as their ability to recall accurate memories is impaired.
A: Projection is a defense mechanism where one attributes their own feelings or thoughts to others.
B: Perseveration is the repetition of a particular response despite the absence or cessation of a stimulus.
C: Agnosia is the inability to recognize or interpret sensory information.
Summary: The other choices are incorrect because they do not specifically address the creation of false memories to compensate for memory deficits, which is characteristic of confabulation in individuals with dementia.