Nokea
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 or distortion of actual memories without the intention to deceive. In this scenario, the client is not intentionally lying, but rather recalling a memory that did not occur. This is common in individuals with dementia. Projection (A) involves attributing one's thoughts or feelings to someone else. Perseveration (B) is the persistent repetition of a response. Agnosia (C) is the inability to recognize familiar objects or people. In this case, the client's statement aligns most closely with confabulation, making it the correct choice.
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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. This intervention helps the client explore and process underlying emotions contributing to self-mutilation. It promotes emotional awareness and healthy coping mechanisms. Restricting personal belongings (A) may escalate feelings of frustration. Seclusion (C) can be traumatic and worsen abandonment fears. Telling the client to stop (D) oversimplifies a complex issue and may lead to resistance.
A nurse is caring for a client with schizophrenia who is experiencing auditory hallucinations. Which intervention should the nurse implement first?
- A. Ask the client what the voices are saying
- B. Tell the client the voices are not real
- C. Encourage the client to listen to music
- D. Teach the client deep breathing exercises
Correct Answer: A
Rationale: The correct answer is A: Ask the client what the voices are saying. This intervention should be implemented first because it helps the nurse assess the content of the hallucinations and understand the client's experience. By asking about the voices, the nurse can gather important information to develop an appropriate care plan. Choice B is incorrect as it denies the client's experience and may lead to mistrust. Choice C may provide temporary distraction but does not address the hallucinations directly. Choice D may help with anxiety but does not specifically address the auditory hallucinations. It is crucial to prioritize understanding the client's perception and providing appropriate support.
A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan?
- A. Place the client in seclusion when he exhibits signs of anxiety.
- B. Encourage the client to spend time in the dayroom.
- C. Withdraw the client's TV privileges if he does not attend group therapy.
- D. Encourage the client to take frequent rest periods.
Correct Answer: D
Rationale: The correct answer is D: Encourage the client to take frequent rest periods. During manic episodes in bipolar disorder, individuals often experience decreased need for sleep and increased energy levels. Encouraging the client to take rest periods can help prevent exhaustion and promote relaxation, which may help in managing manic symptoms. Placing the client in seclusion when anxious (choice A) can exacerbate feelings of isolation and distress. Encouraging the client to spend time in the dayroom (choice B) may increase stimulation, which can worsen manic symptoms. Withdrawing TV privileges (choice C) for not attending group therapy may not directly address the manic symptoms. Thus, choice D is the most appropriate intervention for managing mania in this client.
A nurse is teaching a client who has generalized anxiety disorder about buspirone. Which statement indicates the client understands the teaching?
- A. I should take this medication as needed for acute anxiety.
- B. I may experience sedation and drowsiness with this medication.
- C. I should avoid grapefruit juice while taking this medication.
- D. This medication has a risk for dependence.
Correct Answer: C
Rationale: The correct answer is C: "I should avoid grapefruit juice while taking this medication." This is because grapefruit juice can interact with buspirone and increase the risk of side effects. Option A is incorrect because buspirone is usually taken regularly, not as needed. Option B is incorrect because sedation and drowsiness are uncommon side effects of buspirone. Option D is incorrect because buspirone is not associated with dependence or abuse potential.
A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist's notes. Which of the following responses should the nurse make?
- A. "Are you not happy with your treatment?"
- B. "Why are you interested in seeing your therapist's notes?"
- C. "We can provide a copy of your records, but the therapist's notes are not included."
- D. "I don't think you will benefit from reviewing your therapist's notes right now."
Correct Answer: C
Rationale: The correct response is C: "We can provide a copy of your records, but the therapist's notes are not included." This response aligns with ethical guidelines and laws that protect the confidentiality of therapist-client communication. Providing therapist's notes without proper authorization may breach confidentiality and harm the therapeutic relationship. Other choices lack professionalism and may undermine the client's trust. Option A implies judgment and defensiveness. Option B can be seen as intrusive and may put the client on the defensive. Option D dismisses the client's request and may discourage open communication. Overall, option C respects confidentiality, maintains boundaries, and upholds the client's right to privacy.