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A nurse is assessing a client with generalized anxiety disorder (GAD) who reports difficulty concentrating and feeling restless. What is the most appropriate nursing intervention?
- A. Encourage the client to avoid caffeine.
- B. Suggest the client take up a new hobby.
- C. Teach the client deep breathing exercises.
- D. Refer the client to group therapy.
Correct Answer: C
Rationale: Teaching deep breathing exercises is the most appropriate intervention for a client with generalized anxiety disorder (GAD) experiencing difficulty concentrating and restlessness. Deep breathing exercises are a proven technique to help manage anxiety symptoms, promote relaxation, and improve concentration. Encouraging the client to avoid caffeine (Choice A) may be beneficial, but it is not the most direct intervention for the reported symptoms. Suggesting the client take up a new hobby (Choice B) may be helpful for overall well-being but does not directly address the immediate symptoms. Referring the client to group therapy (Choice D) may be beneficial in the long term, but teaching deep breathing exercises is more immediate and can be easily implemented by the client in various settings.
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A client with obsessive-compulsive disorder (OCD) spends several hours a day arranging and rearranging items in their room. What is the most therapeutic nursing intervention?
- A. Distract the client with another activity.
- B. Allow the client to continue the behavior.
- C. Set a time limit for the behavior.
- D. Encourage the client to verbalize their feelings.
Correct Answer: D
Rationale: Encouraging the client to verbalize their feelings is the most therapeutic intervention for a client with OCD spending excessive time on compulsive behaviors. By expressing their feelings, the client can explore the underlying anxiety that drives the compulsion. This intervention also provides an opportunity for the nurse to offer support and help the client develop coping strategies.\n
Choice A, distracting the client with another activity, may provide temporary relief but does not address the root cause of the behavior.\n
Choice B, allowing the client to continue the behavior, does not promote therapeutic progress and may perpetuate the compulsion.\n
Choice C, setting a time limit for the behavior, may create additional stress for the client and does not address the underlying emotional issues associated with OCD.
A male client who is participating in an anger management assignment asks if he can make a leather belt in occupational therapy. The client begins pounding the leather vigorously with a mallet to imprint designs on the belt. What defense mechanism is the client using?
- A. Sublimation
- B. Suppression
- C. Regression
- D. Compensation
Correct Answer: A
Rationale: The correct answer is A, Sublimation. Sublimation is a defense mechanism where unacceptable impulses are redirected into socially acceptable activities, such as art or work. In this scenario, the client is channeling his anger into a creative and constructive task like making a leather belt. Choice B, Suppression, involves consciously pushing down or hiding feelings rather than expressing them through alternate means. Choice C, Regression, refers to reverting to earlier, immature behaviors when faced with stress. Choice D, Compensation, involves making up for a perceived weakness in one area by excelling in another, which is not demonstrated in the scenario provided.
The nurse observes a female client with schizophrenia watching the news on TV. She begins to laugh softly and says, 'Yes, my love, I'll do it.' When the nurse questions the client about her comment, she states, 'The news commentator is my lover, and he speaks to me each evening. Only I can understand what he says.' What is the best response for the nurse to make?
- A. What do you believe the news commentator said to you?
- B. Let's watch the news on a different television channel.
- C. Does the news commentator have plans to harm you or others?
- D. The news commentator is not talking to you.
Correct Answer: A
Rationale: The correct response for the nurse is to ask the client, 'What do you believe the news commentator said to you?' This is important to determine the content of the auditory hallucination and understand the client's perception. Choice B is incorrect as changing the TV channel does not address the underlying issue. Choice C is incorrect as it introduces a paranoid idea that the news commentator may have harmful intentions, which is not supported by the scenario. Choice D is incorrect as it dismisses the client's belief without exploring or validating her experience.
Which action is most important for the nurse to implement during the initial interview for a client who is admitted to the mental health unit?
- A. Establish rapport in each phase of the nurse-client relationship.
- B. Determine the client's ability to communicate effectively.
- C. Reflect on previous psychiatric interviews the nurse has performed.
- D. Ensure data is collected and recorded in a systematic sequence.
Correct Answer: A
Rationale: Establishing rapport is the most important action during the initial interview for a client admitted to the mental health unit. Building rapport helps create a trusting relationship between the nurse and the client, which is essential for effective communication and the success of the therapeutic relationship. Choice B, determining the client's ability to communicate effectively, is important but secondary to establishing rapport. Choice C, reflecting on previous psychiatric interviews, is not as critical during the initial interview with a new client. Choice D, ensuring data collection and recording in a systematic sequence, is important but comes after establishing rapport to foster a therapeutic environment.
A client with schizophrenia is experiencing distressful thoughts secondary to paranoia. Which intervention(s) should the LPN/LVN include in the plan of care? Select one intervention that does not apply.
- A. Avoid laughing when near the client
- B. Whisper when communicating near the client
- C. Increase socialization of the client among peers
- D. Have the client sign a written release of information form
Correct Answer: B
Rationale: The correct intervention for a client with schizophrenia experiencing distressful thoughts secondary to paranoia is to avoid laughing when near the client. This is important as laughter can be misinterpreted and exacerbate the client's paranoia. Whispering when communicating near the client is not an appropriate intervention as it may lead the client to think secretive or negative information is being shared about them, further fueling their paranoia. Increasing socialization among peers can help provide support and reduce feelings of isolation, while having the client sign a written release of information form is not directly related to managing paranoia and distressful thoughts.