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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 crucial in ensuring the safety and well-being of the client in seclusion and restraints. Documenting the client's behavior every 15 minutes allows the nurse to monitor for any changes in the client's condition, response to the intervention, or signs of distress. It helps in identifying any potential risks or improvements, enabling timely intervention or adjustment of the care plan. This frequent documentation also ensures compliance with regulatory standards and serves as a detailed record of the client's status during the intervention.
Other choices are incorrect:
A: Ensuring prescription renewal every 6 hours may be too frequent and not necessary unless there are specific indications.
C: Requesting a provider evaluation every 36 hours may not provide timely assessment and intervention in case of any changes in the client's condition.
D: Monitoring the client every 30 minutes while restrained may not be frequent enough to detect sudden changes or risks promptly.
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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 manic episodes in bipolar disorder, individuals often experience decreased need for sleep and increased energy levels. Encouraging the client to take rest periods can help prevent exhaustion and promote relaxation, which may help in managing manic symptoms. Placing the client in seclusion when anxious (choice A) can exacerbate feelings of isolation and distress. Encouraging the client to spend time in the dayroom (choice B) may increase stimulation, which can worsen manic symptoms. Withdrawing TV privileges (choice C) for not attending group therapy may not directly address the manic symptoms. Thus, choice D is the most appropriate intervention for managing mania in this client.
A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist's notes. Which of the following responses should the nurse make?
- A. "Are you not happy with your treatment?"
- B. "We can provide a copy of your records, but the therapist's notes are not included."
- C. "Why are you interested in seeing your therapist's notes?"
- D. "I don't think you will benefit from reviewing your therapist's notes right now."
Correct Answer: B
Rationale: The correct answer is B because therapist's notes are considered privileged information and are not typically included in a client's medical records. Providing these notes could compromise the therapeutic relationship and confidentiality. Option A is incorrect as it assumes the client is unhappy with treatment. Option C is inappropriate as it questions the client's motivation. Option D is incorrect as it dismisses the client's request without proper justification. Options E, F, and G are not provided, but B is the most appropriate response in this scenario.
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 or distortion of actual memories without the intention to deceive. In this scenario, the client is not intentionally lying, but rather recalling a memory that did not occur. This is common in individuals with dementia. Projection (A) involves attributing one's thoughts or feelings to someone else. Perseveration (B) is the persistent repetition of a response. Agnosia (C) is the inability to recognize familiar objects or people. In this case, the client's statement aligns most closely with confabulation, making it the correct choice.
A client with schizophrenia is prescribed risperidone. Which of the following should the nurse monitor for as an adverse effect of this medication?
- A. Increased blood pressure
- B. Weight gain
- C. Excessive salivation
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Weight gain. Risperidone, an atypical antipsychotic, is known to cause metabolic side effects such as weight gain. This occurs due to its effects on increasing appetite and altering metabolism. Monitoring weight regularly is crucial to detect and manage this adverse effect to prevent complications like diabetes and cardiovascular issues. Increased blood pressure (A) is not a common adverse effect of risperidone. Excessive salivation (C) is more commonly associated with medications like clozapine. Bradycardia (D) is not a typical side effect of risperidone.
A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state?
- A. "What are the voices telling you?"
- B. "I realize the voices are real to you, but I don't hear anything."
- C. "Have you taken your medication today?"
- D. "How long have you been hearing the voices?"
Correct Answer: A
Rationale: The correct answer is A: "What are the voices telling you?" This response demonstrates active listening, assesses the content of the hallucinations, and helps the nurse understand the client's experience. It allows for further assessment and intervention planning. Choice B dismisses the client's experience, choice C focuses on medication compliance rather than addressing the immediate concern, and choice D addresses the duration of the hallucinations but doesn't address the current situation.