Nokea
A nurse is admitting a client who is exhibiting manic behavior. The client reports recent personal stressors including the loss of her mother and a divorce. Which of the following is the priority nursing action?
- A. Identifying support systems.
- B. Assisting the client in identifying coping behaviors.
- C. Encouraging self-care.
- D. Preventing self-directed violence.
Correct Answer: D
Rationale: Safety is the priority for clients experiencing manic episodes, as they are at risk for self-harm.
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A nurse on an inpatient mental health unit is caring for a client who has major depressive disorder and malnutrition. Which of the following actions should the nurse take to improve the client's nutritional status?
- A. Enroll the client in a nutritional class on the unit.
- B. Weigh the client at the same time every morning.
- C. Ask the provider to arrange a consultation with the facility chaplain.
- D. Sit with the client during meals and snacks.
Correct Answer: D
Rationale: The correct answer is D: Sit with the client during meals and snacks. This option promotes a therapeutic relationship, encourages the client to eat, and provides emotional support. By sitting with the client, the nurse can monitor food intake, address any eating difficulties, and offer encouragement. This approach helps the client feel supported and valued, which can positively impact their nutritional intake.
Choice A is incorrect as a nutritional class may not address the client's immediate needs. Choice B is incorrect as weighing the client daily does not directly improve their nutritional status. Choice C is incorrect as involving the chaplain may not address the nutritional needs of the client.
A nurse is admitting a client who has multiple injuries following a motor vehicle crash. Shortly after admission, the client's partner arrives. He is distraught and blames himself for the accident. Which of the following responses should the nurse make?
- A. "Do not worry about that. Your wife will be fine."
- B. "I think you should calm down a little before you see your partner."
- C. "Why do you think the crash is your fault?"
- D. "Tell me more about your feelings about what happened to your partner."
Correct Answer: D
Rationale: Encouraging the partner to express emotions helps with emotional processing and coping.
A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?
- A. Isolate the client for a period of time.
- B. Confront the client about the senseless nature of the repetitive behaviors.
- C. Plan the client's schedule to allow time for rituals.
- D. Set strict limits on the behaviors so that the client can conform to the unit rules and schedules.
Correct Answer: C
Rationale: The correct answer is C: Plan the client's schedule to allow time for rituals. This is the most appropriate action as it acknowledges the client's need for engaging in compulsive behaviors while also structuring the time effectively. Isolating the client (Choice A) would be counterproductive, as social isolation can exacerbate OCD symptoms. Confronting the client (Choice B) may lead to increased anxiety and resistance. Setting strict limits (Choice D) can cause distress and potential non-compliance. The key is to support the client by incorporating their rituals into the schedule while working towards gradually reducing them in a therapeutic manner.
A nurse is counseling a client for the management of anxiety. The client is consistently late for appointments and ignores household chores. The client states, "I'm just too stressed. I need someone to take care of me.” The nurse identifies this behavior as an example of which of the following defense mechanisms?
- A. Dissociation
- B. Introjection
- C. Regression
- D. Repression
Correct Answer: C
Rationale: The correct answer is C: Regression. Regression is a defense mechanism where an individual reverts to an earlier stage of development when faced with stressful situations. In this scenario, the client's behavior of being consistently late and avoiding responsibilities reflects a regression to a state where they feel the need to be taken care of, like a child seeking comfort from a caregiver. This behavior is a way of coping with anxiety by seeking refuge in a familiar and less demanding role. Dissociation (A) involves disconnecting from reality to avoid distress, introjection (B) is internalizing the qualities of others, and repression (D) is unconsciously suppressing unwanted thoughts or memories.
A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client’s head is down, and he is wringing his hands. Which of the following actions should the nurse take?
- A. Encourage the client to go back to bed.
- B. Give the client a PRN sleeping medication.
- C. Remain with the client.
- D. Explore alternatives to pacing the floor with the client.
Correct Answer: C
Rationale: The correct answer is C: Remain with the client. By remaining with the client, the nurse can provide support and reassurance, assess the client's emotional state, and ensure the client's safety. This action shows empathy and promotes therapeutic communication. Encouraging the client to go back to bed (A) may not address the underlying issue causing the restlessness. Giving a PRN sleeping medication (B) without further assessment may not be appropriate and could mask the client's feelings. Exploring alternatives to pacing (D) is a good intervention but should come after providing immediate support and understanding the client's needs.