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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 young adult male with a history of substance abuse is admitted to the psychiatric unit for detoxification. He is agitated, sweating, and reports seeing bugs crawling on the walls. What is the priority nursing intervention?
- A. Reassure the client that the bugs are not real.
- B. Administer the prescribed benzodiazepine.
- C. Place the client in a quiet, dark room.
- D. Encourage the client to express his feelings.
Correct Answer: B
Rationale: The correct answer is to administer the prescribed benzodiazepine. This intervention helps manage the client's agitation and hallucinations, which are common symptoms during detoxification from substances. Reassuring the client that the bugs are not real (Choice A) may not be effective in addressing the underlying causes of the hallucinations. Placing the client in a quiet, dark room (Choice C) may help reduce sensory stimulation but does not directly address the client's symptoms. Encouraging the client to express his feelings (Choice D) is important for therapeutic communication but may not be the priority when the client is experiencing severe agitation and hallucinations.
A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage?
- A. He ingested the drug 3 hours prior to admission to the emergency center.
- B. The family reports that he took an entire bottle of acetaminophen (Tylenol).
- C. He is unresponsive to instructions and is unable to cooperate with emetic therapy.
- D. Those with repeated suicide attempts desire punishment to relieve their guilt.
Correct Answer: C
Rationale: The correct answer is C because the client's unresponsiveness and inability to cooperate with emetic therapy indicate the need for gastric lavage. Gastric lavage is a procedure used to remove toxic substances from the stomach in cases where the patient is unresponsive or unable to cooperate. Choice A is incorrect as the time of ingestion alone does not indicate the need for gastric lavage. Choice B, although indicating a significant overdose, does not directly necessitate gastric lavage. Choice D is incorrect as it provides information about the possible psychological motivation for repeated suicide attempts, but it is not directly related to the immediate need for gastric lavage in this scenario.
At a support meeting of parents of a teenager with polysubstance dependency, a parent states, 'Each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide.' The nurse's response should be based on which information?
- A. Addiction is a chronic, incurable disease.
- B. Tolerance to the effects of drugs causes feelings of depression.
- C. Feelings of depression frequently lead to drug abuse and addiction.
- D. Careful monitoring should be provided during withdrawal from the drugs.
Correct Answer: C
Rationale: The correct response in this situation should focus on the connection between feelings of depression and drug abuse. Choice A is incorrect because addiction is treatable, not incurable. Choice B is incorrect as tolerance does not directly cause depression. Choice D is not the best response as the parent's concern is about the son's depression leading to suicidal thoughts, not just the withdrawal process.
At the first meeting of a group of older adults at a daycare center for the elderly, the LPN/LVN asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, 'You tell me, you're the leader.' What is the best response for the nurse to make?
- A. Yes, I am the leader today. Would you like to be the leader tomorrow?
- B. Yes, I will be leading this group. What would you like to accomplish during this time?
- C. Yes, I have been assigned to be the leader of this group. I will be here for the next six weeks.
- D. Yes, I am the leader. You seem angry about not being the leader yourself.
Correct Answer: B
Rationale: The best response for the nurse is choice B: 'Yes, I will be leading this group. What would you like to accomplish during this time?' This response acknowledges the member's comment and encourages her to share her interests, promoting engagement and active participation in group activities. Choice A is not as inclusive and may not foster collaboration within the group. Choice C focuses more on the nurse's assignment rather than addressing the member's input. Choice D assumes emotions that were not expressed by the group member and does not encourage open communication.