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A nurse in an inpatient mental health facility is planning care for a client who has schizophrenia and is experiencing delusions. Which of the following interventions should the nurse include?
- A. Encourage the client to focus on reality-based topics
- B. Agree with the client’s delusional beliefs
- C. Discuss the delusions in detail
- D. Provide frequent reassurance about safety
Correct Answer: A
Rationale: The correct answer is A: Encourage the client to focus on reality-based topics. This intervention is appropriate because it helps the client ground themselves in reality and potentially reduce the intensity of their delusions. By redirecting the client's focus to reality-based topics, the nurse can help them challenge and eventually overcome their delusions. Choices B, C, and D are incorrect. Agreeing with delusional beliefs can reinforce them, discussing delusions in detail may exacerbate them, and providing frequent reassurance about safety may not address the underlying issue of delusions.
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A nurse is caring for a client who has posttraumatic stress disorder related to military service. Which of the following actions should the nurse take?
- A. Encourage the client to suppress feelings of trauma
- B. Assign the same staff to care for the client each day
- C. Address the client in an authoritative manner
- D. Limit the amount of time spent with the client
Correct Answer: B
Rationale: The correct answer is B: Assign the same staff to care for the client each day. Consistency in care providers helps establish trust and a sense of safety for clients with PTSD. This familiarity can reduce anxiety and improve therapeutic rapport. Encouraging the client to suppress feelings of trauma (A) can be harmful as it may worsen symptoms. Addressing the client in an authoritative manner (C) can trigger feelings of threat. Limiting time spent with the client (D) can hinder the development of a therapeutic relationship.
A nurse is providing teaching to the daughter of an older client who has obsessive-compulsive disorder. Which of the following statements by the daughter indicates an understanding of the disorder?
- A. I will limit my mother’s clothing choices when she is getting dressed
- B. I will provide my mother with detailed instructions about how to perform self-care
- C. I will wake my mother up a couple of times in the night to check on her
- D. I will discourage my mother from talking about physical complaints
Correct Answer: B
Rationale: The correct answer is B: "I will provide my mother with detailed instructions about how to perform self-care." This statement indicates an understanding of obsessive-compulsive disorder (OCD) because individuals with OCD often struggle with performing daily tasks due to their obsessive thoughts and compulsive behaviors. By providing detailed instructions, the daughter is acknowledging the need for structured routines to help her mother manage her symptoms.
A: Limiting clothing choices does not address the underlying issues of OCD and may exacerbate anxiety.
C: Waking the mother up to check on her reinforces compulsions, which is counterproductive in treating OCD.
D: Discouraging the mother from talking about physical complaints does not address the core symptoms of OCD.
By choosing option B, the daughter shows insight into the importance of providing support and guidance in managing the challenges associated with OCD.
A nurse is assessing a client who has alcohol use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Visual hallucinations
- C. Hyperactivity
- D. Increased appetite
Correct Answer: B
Rationale: The correct answer is B: Visual hallucinations. During alcohol withdrawal, the client may experience hallucinations, particularly visual ones, due to the impact of alcohol on the brain. This is known as alcohol hallucinosis. Hypotension (choice A) is not typically associated with alcohol withdrawal; in fact, hypertension is more common. Hyperactivity (choice C) is not a common symptom of alcohol withdrawal, as clients tend to be more agitated or restless. Increased appetite (choice D) is also not a typical finding during alcohol withdrawal, as many clients experience decreased appetite. Visual hallucinations are a key symptom to monitor for during alcohol withdrawal due to their potential to be distressing and require immediate intervention.
A nurse in a provider’s office is assessing a school-age child who has a spiral fracture. The parent of the child provides different accounts for the cause of the injury. Which of the following actions should the nurse take first?
- A. Request that the parent leaves the room while you interview the child
- B. Report suspected abuse to child protective services
- C. Ask the child how the injury occurred
- D. Determine the immediate safety needs of the child
Correct Answer: B
Rationale: Correct Answer: B. Report suspected abuse to child protective services.
Rationale: Reporting suspected abuse to child protective services is the first step to ensure the safety and well-being of the child. In cases of conflicting stories from the parent and the child, it is crucial to prioritize the child's safety. Child protective services can investigate further to determine the true cause of the injury and provide necessary support and protection for the child.
Summary of other choices:
A: Requesting the parent to leave the room may be necessary for further assessment, but ensuring the child's safety is the priority.
C: Asking the child how the injury occurred is important but should come after ensuring the child's immediate safety.
D: Determining the immediate safety needs of the child is crucial, but reporting suspected abuse takes precedence to address potential harm.
A nurse in a psychiatric unit is planning care for a client who has paranoid personality disorder. Which of the following interventions should the nurse include?
- A. Encourage group therapy participation
- B. Avoid challenging the client’s paranoid beliefs
- C. Maintain eye contact during conversations
- D. Use humor to reduce the client’s anxiety
Correct Answer: B
Rationale: The correct answer is B: Avoid challenging the client’s paranoid beliefs. This is essential because challenging the client's beliefs can lead to increased defensiveness and mistrust. Instead, the nurse should validate the client's feelings without reinforcing the delusions. Encouraging group therapy (choice A) may exacerbate paranoia by increasing feelings of being scrutinized. Maintaining eye contact (choice C) may be perceived as threatening. Using humor (choice D) could be misinterpreted and lead to further distrust.