A nurse is assessing a client who has bipolar disorder and is experiencing a depressive episode. Which of the following findings should the nurse expect?
- A. Inability to carry out a simple task
- B. Client reports auditory hallucinations
- C. Moves quickly from one idea to the next
- D. Client expresses illusions of grandeur
Correct Answer: A
Rationale: The correct answer is A: Inability to carry out a simple task. During a depressive episode in bipolar disorder, individuals often experience cognitive impairment, including difficulty concentrating and making decisions. This can lead to an inability to carry out simple tasks. Choices B, C, and D are more indicative of symptoms seen in manic episodes, such as auditory hallucinations (B), racing thoughts (C), and grandiosity (D). By understanding the characteristic symptoms of bipolar disorder episodes, the nurse can appropriately assess and provide interventions for the client.
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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 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 address underlying emotions driving self-mutilation, promoting self-awareness and healthier coping mechanisms. Option A may escalate feelings of lack of control, triggering more self-harm. Option C isolates the client, worsening feelings of abandonment. Option D is dismissive and oversimplifies the behavior.
A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?
- A. I can continue to take St. John's wort while taking this medication.
- B. I know it will be a couple of weeks before the medication helps me feel better.
- C. I expect this medication to raise my blood pressure.
- D. I should take this medication on an empty stomach.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
- Choice B indicates an understanding of the delayed onset of action of amitriptyline, which typically takes a couple of weeks to produce therapeutic effects.
- This knowledge is crucial for managing client expectations and adherence to treatment.
- Choices A, C, and D are incorrect:
- A: Taking St. John's wort with amitriptyline can result in serotonin syndrome due to potential drug interactions.
- C: Amitriptyline can actually lower blood pressure, not raise it.
- D: Amitriptyline is usually taken with food to minimize gastrointestinal side effects.
- In summary, choice B reflects the correct understanding of the medication's timeline for efficacy, while the other choices demonstrate misconceptions or potential risks.
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, C, is appropriate because therapist's notes are considered confidential and are not typically shared with clients. Providing a copy of the client's records without the therapist's notes is in line with maintaining client confidentiality and upholding ethical standards in mental health practice. Choice A is incorrect as it assumes the client is unhappy with their treatment without any basis. Choice B is not ideal as it probes the client's reasons, potentially violating their privacy. Choice D is inappropriate as it undermines the client's autonomy and right to access their records.
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. "We can provide a copy of your records, but the therapist's notes are not included."
- C. "Why are you interested in seeing your therapist's notes?"
- D. "I don't think you will benefit from reviewing your therapist's notes right now."
Correct Answer: B
Rationale: The correct answer is B because therapist's notes are considered privileged information and are not typically included in a client's medical records. Providing these notes could compromise the therapeutic relationship and confidentiality. Option A is incorrect as it assumes the client is unhappy with treatment. Option C is inappropriate as it questions the client's motivation. Option D is incorrect as it dismisses the client's request without proper justification. Options E, F, and G are not provided, but B is the most appropriate response in this scenario.