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A nurse is admitting an older adult client who has a suspected cognitive disorder. Which of the following inventories should be included as part of the admission assessment?
- A. Mental Status Examination (MSE)
- B. Brief Patient Health Questionnaire (Brief PHQ)
- C. Abnormal Involuntary Movements Scale (AIMS)
- D. Scale for Assessment of Negative Symptoms (SANS)
Correct Answer: A
Rationale: The correct answer is A: Mental Status Examination (MSE). A MSE is crucial to assess cognitive function, orientation, memory, attention, and other mental aspects in older adults with suspected cognitive disorders. It helps identify cognitive deficits and guide appropriate interventions. Brief PHQ (B) focuses on mood disorders, AIMS (C) evaluates movement disorders, and SANS (D) assesses negative symptoms in psychiatric disorders, which are not specific to cognitive disorders. In summary, the MSE is the most relevant tool for assessing cognitive functions in this scenario.
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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 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.
A nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?
- A. Disclose some personal information to the client to demonstrate approachability.
- B. Wait for the client to initiate interaction.
- C. Approach the client frequently throughout the day for brief interactions.
- D. Adopt a neutral attitude when providing care.
Correct Answer: D
Rationale: The correct answer is D: Adopt a neutral attitude when providing care. This approach is appropriate because it helps to build trust with a suspicious client by not evoking any feelings of threat or manipulation. By maintaining a neutral attitude, the nurse can establish a safe and non-threatening environment for the client to gradually open up and develop a therapeutic relationship.
Other choices are incorrect because:
A: Disclosing personal information may blur professional boundaries and make the client more suspicious.
B: Waiting for the client to initiate interaction may prolong the time it takes to establish a connection.
C: Approaching the client frequently may overwhelm the client and reinforce their suspicions.
E, F, G: These options are not provided in the question, so they cannot be evaluated.
A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take first?
- A. Implement the client's behavioral modification plan.
- B. Document the size and location of the cuts.
- C. Assess the client's intent and suicide risk.
- D. Administer a tetanus antitoxin.
Correct Answer: C
Rationale: The correct answer is C: Assess the client's intent and suicide risk. This is the first action the nurse should take to ensure the immediate safety of the client. By assessing the client's intent and suicide risk, the nurse can determine the severity of the situation and the appropriate level of intervention needed. This assessment will guide the nurse in developing a safety plan to prevent further self-harm or potential suicide attempts.
Choice A is incorrect because implementing the client's behavioral modification plan is not the priority when the client is actively engaging in self-harm behavior.
Choice B is incorrect as documenting the size and location of the cuts can be done after ensuring the client's immediate safety.
Choice D is incorrect as administering a tetanus antitoxin is not the priority in this situation and does not address the client's emotional and psychological needs.
In summary, assessing the client's intent and suicide risk is the most critical step to ensure the client's safety and well-being in a situation involving self-h
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.