Nokea
A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?
- A. Prepare for gastric lavage due to an extremely elevated lithium level.
- B. Administer the morning dose of lithium.
- C. Check the client's medication record to assess whether the client has been refusing her lithium.
- D. Hold the medication and assess for early manifestations of toxicity.
Correct Answer: B
Rationale: A lithium level of 1.0 mEq/L is within the therapeutic range (0.6-1.2 mEq/L).
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A nurse is admitting a client who has multiple injuries following a motor vehicle crash. Shortly after admission, the client's partner arrives. He is distraught and blames himself for the accident. Which of the following responses should the nurse make?
- A. "Do not worry about that. Your wife will be fine."
- B. "I think you should calm down a little before you see your partner."
- C. "Why do you think the crash is your fault?"
- D. "Tell me more about your feelings about what happened to your partner."
Correct Answer: D
Rationale: Encouraging the partner to express emotions helps with emotional processing and coping.
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 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.
A client awaiting surgery expresses fear of having cancer. Which response by the nurse is most appropriate?
- A. "Why do you think you have cancer?"
- B. "I don't see any reason for you to worry."
- C. "That's something to discuss with your provider."
- D. "I hear that you are concerned about this."
Correct Answer: D
Rationale: The correct answer is D because it acknowledges the client's feelings and shows empathy. By saying, "I hear that you are concerned about this," the nurse validates the client's emotions and creates a supportive environment. Choice A is incorrect as it may come off as dismissive. Choice B is inappropriate as it invalidates the client's fear. Choice C passes the responsibility back to the client's provider instead of addressing the immediate concern.
A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?
- A. Isolate the client for a period of time.
- B. Confront the client about the senseless nature of the repetitive behaviors.
- C. Plan the client's schedule to allow time for rituals.
- D. Set strict limits on the behaviors so that the client can conform to the unit rules and schedules.
Correct Answer: C
Rationale: The correct answer is C: Plan the client's schedule to allow time for rituals. This is the most appropriate action as it acknowledges the client's need for engaging in compulsive behaviors while also structuring the time effectively. Isolating the client (Choice A) would be counterproductive, as social isolation can exacerbate OCD symptoms. Confronting the client (Choice B) may lead to increased anxiety and resistance. Setting strict limits (Choice D) can cause distress and potential non-compliance. The key is to support the client by incorporating their rituals into the schedule while working towards gradually reducing them in a therapeutic manner.