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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. During adolescence, individuals go through Erikson's stage of Identity vs role confusion, where they explore and develop their own sense of self and try to establish a clear identity. This stage typically occurs during the teenage years, when adolescents are trying to figure out who they are, what they believe in, and what roles they want to play in society. This is a crucial period for developing a strong sense of self and personal identity.
Choices A, B, and C are incorrect because they correspond to different stages in Erikson's theory that do not align with the developmental tasks of adolescence. Generativity vs self-absorption is a stage typically seen in middle adulthood, Trust vs mistrust is seen in infancy, and Intimacy vs isolation is seen in early adulthood. These stages do not apply to the adolescent age group and their current developmental needs.
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A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)
- A. Give the client one simple direction at a time.
- B. Refute the client's delusions using logic.
- C. Allow the client to choose among a variety of activities each day.
- D. Reinforce orientation to time, place, and person.
- E. Establish eye contact when communicating with the client.
Correct Answer: A, D, E
Rationale: Correct Answer: A, D, E
Rationale:
A: Giving the client one simple direction at a time is important as individuals with dementia may have difficulty processing complex information.
D: Reinforcing orientation to time, place, and person helps maintain the client's sense of reality and reduce confusion.
E: Establishing eye contact when communicating with the client promotes engagement and helps in maintaining their attention.
Summary:
B: Refuting the client's delusions using logic can be counterproductive as it may cause distress and worsen their symptoms.
C: Allowing the client to choose among a variety of activities may overwhelm them. It is better to provide structured activities.
F & G: Not applicable.
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 creation of false memories to fill in gaps in memory due to brain dysfunction. In this scenario, the client with dementia is creating a false memory about living in the facility and taking care of all the residents by herself. This is a common phenomenon in individuals with dementia as their ability to recall accurate memories is impaired.
A: Projection is a defense mechanism where one attributes their own feelings or thoughts to others.
B: Perseveration is the repetition of a particular response despite the absence or cessation of a stimulus.
C: Agnosia is the inability to recognize or interpret sensory information.
Summary: The other choices are incorrect because they do not specifically address the creation of false memories to compensate for memory deficits, which is characteristic of confabulation in individuals with dementia.
A nurse is caring for a client with major depressive disorder who has a new prescription for fluoxetine. Which statement by the client indicates an understanding of the medication?
- A. I should expect to see improvement in my mood within a few days.
- B. I may experience increased thoughts of suicide at the beginning of treatment.
- C. I need to avoid foods high in tyramine while taking this medication.
- D. I will need to have my lithium levels checked regularly.
Correct Answer: B
Rationale: The correct answer is B. This statement indicates an understanding of the medication because it acknowledges the possibility of increased thoughts of suicide at the beginning of treatment, which is a crucial side effect to monitor for in clients starting on antidepressants like fluoxetine. It shows that the client is aware of the potential risks associated with the medication and is prepared to address them with healthcare providers if they occur.
Choice A is incorrect because improvement in mood with fluoxetine typically takes several weeks, not a few days. Choice C is incorrect as tyramine-related dietary restrictions are associated with MAOIs, not SSRIs like fluoxetine. Choice D is incorrect as lithium levels are not monitored with fluoxetine therapy.
A nurse is caring for a client with major depressive disorder who has a new prescription for fluoxetine. Which statement by the client indicates an understanding of the medication?
- A. I should expect to see improvement in my mood within a few days.
- B. I may experience increased thoughts of suicide at the beginning of treatment.
- C. I need to avoid foods high in tyramine while taking this medication.
- D. I will need to have my lithium levels checked regularly.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Fluoxetine is an antidepressant that can initially increase suicidal thoughts in some individuals, especially at the beginning of treatment.
2. This phenomenon is known as "activation syndrome" and is important for clients to be aware of.
3. Monitoring for any signs of increased suicidal thoughts is crucial for client safety.
4. Options A, C, and D are incorrect because fluoxetine does not provide immediate mood improvement, does not require avoiding tyramine-rich foods, and does not affect lithium levels.
A nurse is planning care for a client who has borderline personality disorder and engages in self-mutilation. Which intervention should the nurse include?
- A. Restrict the client's access to personal belongings.
- B. Encourage the client to express feelings of anger.
- C. Place the client in seclusion when self-injurious behavior occurs.
- D. Tell the client to stop the self-mutilation behavior.
Correct Answer: B
Rationale: The correct answer is B: Encourage the client to express feelings of anger. For a client with borderline personality disorder and self-mutilation behavior, it is essential to address underlying emotions. Encouraging the client to express feelings of anger can help them identify and process their emotions, reducing the likelihood of resorting to self-injury. Restricting access to personal belongings (A) may lead to feelings of frustration and exacerbate the behavior. Placing the client in seclusion (C) may cause feelings of abandonment and increase distress. Simply telling the client to stop self-mutilation (D) overlooks the complex emotional reasons behind the behavior.