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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 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 unintentional fabrication of memories or events to fill in gaps in memory due to cognitive impairment. In this scenario, the client with dementia is creating false memories of taking care of all the residents by herself, which is a classic example of confabulation. This behavior is not intentional lying but a result of memory deficits.
Choice A: Projection involves attributing one's own unacceptable feelings or thoughts to others, which is not applicable in this context.
Choice B: Perseveration is the repetition of a particular response, such as repeating a word or phrase, which does not align with the client's false memory.
Choice C: Agnosia refers to the inability to recognize familiar objects or people due to brain damage, which is not evident in the client's statement.
A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan?
- A. Encourage the client to lie down in a quiet room.
- B. Refer to the hallucinations as if they are real.
- C. Ask the client directly what he is hearing.
- D. Avoid eye contact with the client.
Correct Answer: C
Rationale: The correct answer is C: Ask the client directly what he is hearing. This is the best action because it acknowledges the client's experience without reinforcing the hallucinations as real. By directly asking the client about their hallucinations, the nurse can gather important information to better understand the client's experience and tailor the care plan accordingly.
Choice A is incorrect because lying down in a quiet room may not address the client's auditory hallucinations. Choice B is incorrect as it can validate the hallucinations as real, which can exacerbate the client's symptoms. Choice D is incorrect as avoiding eye contact can create a barrier to communication.
A nurse in an outpatient mental health clinic is assessing an adolescent client. The nurse should expect the adolescent to be in which of the following of Erikson's stages of psychosocial development?
- A. Generativity vs self-absorption
- B. Trust vs mistrust
- C. Intimacy vs isolation
- D. Identity vs role confusion
Correct Answer: D
Rationale: The correct answer is D: Identity vs role confusion. Adolescents typically fall into this stage, characterized by exploring and establishing their sense of self and identity. They may question their roles and values, seeking to understand who they are. Choice A (Generativity vs self-absorption) is more relevant to middle adulthood. Choice B (Trust vs mistrust) is for infancy. Choice C (Intimacy vs isolation) is for young adulthood.
A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which of the following clients should the nurse see first?
- A. A client who has narcissistic personality disorder and is mocking others during group therapy
- B. A client who has obsessive-compulsive disorder and is upset about a change in daily routine
- C. A client who has depressive disorder and requires assistance with ADLs
- D. A client who is taking clozapine to treat schizophrenia and reports a sore throat
Correct Answer: D
Rationale: The correct answer is D. The nurse should see the client taking clozapine first due to the potential side effect of agranulocytosis, which can manifest as a sore throat. This is a serious adverse effect that requires immediate attention to prevent complications. The other clients do not present with urgent or life-threatening issues. A: Narcissistic behavior is disruptive but not a medical emergency. B: Upset about a routine change is distressing but does not pose a physical health risk. C: Assistance with ADLs is important but not immediately life-threatening. Therefore, prioritizing the client on clozapine with a sore throat is crucial to ensure timely intervention and prevent serious complications.
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. "Why are you interested in seeing your therapist's notes?"
- C. "We can provide a copy of your records, but the therapist's notes are not included."
- D. "I don't think you will benefit from reviewing your therapist's notes right now."
Correct Answer: C
Rationale: The correct response is C: "We can provide a copy of your records, but the therapist's notes are not included." This response aligns with ethical guidelines and laws that protect the confidentiality of therapist-client communication. Providing therapist's notes without proper authorization may breach confidentiality and harm the therapeutic relationship. Other choices lack professionalism and may undermine the client's trust. Option A implies judgment and defensiveness. Option B can be seen as intrusive and may put the client on the defensive. Option D dismisses the client's request and may discourage open communication. Overall, option C respects confidentiality, maintains boundaries, and upholds the client's right to privacy.