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A nurse in an acute mental health facility is creating a plan of care for a new client who has histrionic personality disorder. Which of the following is the priority intervention for the nurse to make?
- A. Promote appropriate behavior during group therapy sessions.
- B. Encourage client input in the treatment plan.
- C. Communicate with the client using concrete language.
- D. Demonstrate assertive behavior.
Correct Answer: A
Rationale: The correct answer is A: Promote appropriate behavior during group therapy sessions. For a client with histrionic personality disorder, the priority intervention is to establish boundaries and promote appropriate behavior to ensure a therapeutic environment. This is crucial in managing attention-seeking behaviors and maintaining focus on the therapeutic goals. Encouraging client input in the treatment plan (B) is important but not the priority at this stage. Communicating with concrete language (C) may be helpful but does not address the immediate need for behavior management. Demonstrating assertive behavior (D) is not the priority as it may escalate the situation.
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A nurse on an acute mental health unit is caring for a client who has major depressive disorder. Which of the following interventions is the nurse’s priority?
- A. Monitor for risk of self-harm.
- B. Administer prescribed antidepressants.
- C. Encourage adequate fluid intake.
- D. Assist with activities of daily living.
Correct Answer: A
Rationale: The correct answer is A: Monitor for risk of self-harm. This is the priority because individuals with major depressive disorder are at an increased risk for suicide. The nurse must ensure the client's safety by closely monitoring for any signs of self-harm or suicidal ideation. Administering antidepressants (B) may be important for long-term management but ensuring immediate safety takes precedence. Encouraging fluid intake (C) and assisting with activities of daily living (D) are important aspects of care but do not address the immediate risk of self-harm.
A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After showing the client to his room, which of the following nursing actions is most therapeutic at this time?
- A. Suggest that the client rest in bed.
- B. Remain with the client for a while.
- C. Medicate the client with a sedative.
- D. Have the client join a therapy group.
Correct Answer: B
Rationale: The correct answer is B: Remain with the client for a while. This is the most therapeutic action as it provides immediate support and reassurance to the client experiencing panic-level anxiety. Remaining with the client allows the nurse to offer a calming presence, demonstrate empathy, and help the client feel safe and supported. It also helps to establish a therapeutic relationship and can assist in de-escalating the client's anxiety.
A: Suggesting the client rest in bed may not address the client's immediate emotional needs and could be perceived as dismissive.
C: Medicating the client with a sedative should only be done after a thorough assessment by a healthcare provider and is not the initial therapeutic action.
D: Having the client join a therapy group may be overwhelming for someone experiencing panic-level anxiety and may not be the most appropriate intervention at this time.
A nurse is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse identify as the primary cause of liver cirrhosis?
- A. Alcohol
- B. Caffeine
- C. Cocaine
- D. Inhalants
Correct Answer: A
Rationale: Chronic alcohol use is the leading cause of liver cirrhosis due to its toxic effects on liver cells.
A nurse is planning discharge for a client who has borderline personality disorder. Which of the following interventions should be included for this client?
- A. Dialectical behavior therapy
- B. Behavioral contract
- C. Milieu therapy
- D. Safety plan
Correct Answer: D
Rationale: The correct answer is D: Safety plan. For a client with borderline personality disorder, a safety plan is crucial to prevent self-harm or suicidal behaviors. This intervention helps the client identify triggers, coping strategies, support resources, and steps to take in a crisis. A: Dialectical behavior therapy is a comprehensive treatment, not just a discharge plan. B: Behavioral contract may not address the immediate safety concerns. C: Milieu therapy focuses on the therapeutic environment, not individual discharge planning.
A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?
- A. Experiencing diarrhea
- B. Exercising moderately
- C. Increasing sodium intake
- D. Drinking green tea
Correct Answer: A
Rationale: The correct answer is A: Experiencing diarrhea. Diarrhea can lead to dehydration and electrolyte imbalances, which can increase lithium levels in the blood and cause toxicity. This is because lithium is primarily excreted by the kidneys, and dehydration can impair its elimination. Options B, C, and D are incorrect because moderate exercise, increasing sodium intake, and drinking green tea are not known to directly cause lithium toxicity. In fact, maintaining adequate hydration and a balanced diet with normal sodium intake can help prevent lithium toxicity.