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A nurse in an acute mental health facility is caring for a client who jumps out of her chair and begins to shout angrily at the clients around her. Which of the following actions should the nurse take first?
- A. Call for assistance to place the client in restraints.
- B. Escort the client to an unlocked seclusion room.
- C. Offer the client a PRN antianxiety medication.
- D. Speak to the client calmly, giving simple directions.
Correct Answer: D
Rationale: The correct answer is D: Speak to the client calmly, giving simple directions. This is the first action the nurse should take because it focuses on de-escalating the situation and ensuring the safety of the client and others. By speaking calmly and giving simple directions, the nurse can help the client regain control and potentially prevent further escalation. Calling for assistance to place the client in restraints (A) should only be used as a last resort for safety reasons. Escorting the client to an unlocked seclusion room (B) may escalate the situation further. Offering a PRN antianxiety medication (C) should only be considered after assessing the client and obtaining an order from a healthcare provider.
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A nurse in a mental health clinic is conducting a staff education session on schizophrenia. Which of the following manifestations should the nurse identify as negative symptoms? (Select all that apply.)
- A. Delusions
- B. Hallucinations
- C. Anhedonia
- D. Poor judgment
- E. Blunt affect
Correct Answer: C, E
Rationale: The correct manifestations for negative symptoms of schizophrenia are C: Anhedonia and E: Blunt affect. Anhedonia refers to the inability to feel pleasure, which is a common negative symptom. Blunt affect is a reduction in the range and intensity of emotional expression, another classic negative symptom. Delusions (A) and hallucinations (B) are positive symptoms involving distorted perceptions and beliefs. Poor judgment (D) is a cognitive symptom, not specific to schizophrenia. The absence of options F and G means they are not applicable to this question.
A nurse is assessing a client who is experiencing chronic stress. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Viral infection
- C. Increased energy
- D. Increased cognitive awareness
Correct Answer: B
Rationale: The correct answer is B: Viral infection. Chronic stress weakens the immune system, making the individual more susceptible to infections like viral illnesses. This is due to the prolonged release of stress hormones, which suppress immune function. Hypotension (A) is unlikely as stress typically raises blood pressure. Increased energy (C) is less likely as chronic stress often leads to fatigue. Increased cognitive awareness (D) is not a common finding with chronic stress, as it can impair cognitive function.
A newly admitted client with obsessive-compulsive disorder (OCD) is performing ritualistic behaviors. What should the nurse do first?
- A. Discuss alternative coping strategies
- B. Identify precipitating factors for rituals
- C. Instruct on relaxation techniques
- D. Provide a structured activity schedule
Correct Answer: B
Rationale: The correct answer is B: Identify precipitating factors for rituals. This is the first step because understanding what triggers the client's rituals is crucial in developing an effective treatment plan. By identifying these factors, the nurse can address the root cause of the behavior and work towards reducing or eliminating it. Discussing coping strategies (A) may come later once the triggers are identified. Instructing on relaxation techniques (C) and providing a structured activity schedule (D) are helpful interventions but addressing the triggers takes precedence.
Where should a nurse assign a client experiencing manic behavior?
- A. Semi-private room across from the day room
- B. Private room in a quiet location
- C. Semi-private room across from the snack area
- D. Shared room near the nursing station
Correct Answer: B
Rationale: The correct answer is B: Private room in a quiet location. This choice is appropriate because a client experiencing manic behavior requires a calm and quiet environment to minimize stimulation and help reduce agitation. Placing the client in a private room can provide the necessary space for the client to calm down and prevent potential triggers for further manic episodes.
Other choices are incorrect:
A: A semi-private room across from the day room may expose the client to increased noise and activity, which can exacerbate manic behavior.
C: A semi-private room across from the snack area may lead to distractions and potential interactions that can escalate the manic behavior.
D: A shared room near the nursing station may not offer the privacy and quiet environment needed for a client experiencing manic behavior to stabilize.
A nurse is caring for a client following a recent suicide attempt. Which of the following actions should the nurse take?
- A. Place metal utensils on the client’s meal tray
- B. Assign the client to a private room
- C. Inspect the client's personal belongings
- D. Tuck bedcovers over the client’s hands and arms
Correct Answer: C
Rationale: The correct answer is C: Inspect the client's personal belongings. This action is crucial to ensure the safety of the client by identifying any potentially harmful items that could be used for another suicide attempt. Placing metal utensils (A) on the tray could pose a risk. Assigning to a private room (B) may isolate the client further. Tucking bedcovers (D) could restrict movement. Other choices are not relevant.