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A nurse is assisting in the care of an adolescent who states
- A. I hate living at home. It's impossible to please my parents. Which of the following responses should the nurse make?
- B. Your parents care for you and want what's best for you.
- C. Let's talk about your relationship with your parents.
- D. Why do you think your parents are hard to please?
- E. Things will get better as time goes on.
Correct Answer: B
Rationale: This response opens up a conversation about the adolescent's feelings and experiences regarding their relationship with their parents. It shows empathy and a willingness to understand the adolescent's perspective, which can help build trust and rapport. By exploring the relationship, the nurse can gather more information and provide appropriate support and guidance.
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A nurse is monitoring a client who is receiving haloperidol. Which of the following findings is the priority to report to the provider?
- A. Hypoactive bowel sounds in all four quadrants.
- B. Client report of dry mouth.
- C. Constant opening and closing of mouth.
- D. Client report of photosensitivity.
Correct Answer: C
Rationale: Constant opening and closing of the mouth, also known as tardive dyskinesia, is a serious side effect of haloperidol and other antipsychotic medications. This condition involves involuntary muscle movements and can be irreversible. It is crucial to report this finding to the provider immediately for assessment and potential adjustment of the medication regimen.
A nurse is reinforcing teaching with a client who is to receive electroconvulsive therapy. Which of the following statements should the nurse include in the teaching?
- A. You will be given an opioid analgesic before the procedure.
- B. Expect to be confused several hours after the procedure.
- C. You cannot eat or drink for 24 hours before the procedure.
- D. A consent form is not required to have this procedure.
Correct Answer: B
Rationale: Confusion and temporary memory loss are common side effects immediately following ECT. Clients should be informed to expect these cognitive effects, which can last for a few hours to days. Educating the client about these side effects helps prepare them for what to expect post-procedure and ensures they have appropriate support during their recovery period.
A nurse is collecting data from a client who experienced physical abuse as a child. Which of the following findings should the nurse identify as a risk factor for the client to become a perpetrator of child abuse?
- A. Low tolerance for frustration.
- B. Involved in community activities.
- C. Submissive personality.
- D. Absence of impulsive behaviors.
Correct Answer: A
Rationale: Low tolerance for frustration is a significant risk factor for becoming a perpetrator of child abuse. Individuals who have difficulty managing their frustration may be more likely to react impulsively and aggressively when faced with challenging situations. This inability to cope with frustration can lead to abusive behaviors, especially if the individual has not developed healthy coping mechanisms.
A nurse is collecting data from a group of clients in an acute care mental health facility. For which of the following findings should the nurse be most concerned regarding individual client safety?
- A. A client who has borderline personality disorder and acts impulsively
- B. A client who has avoidant personality disorder and becomes anxious in social situations
- C. A client who has dependent personality disorder and clings to nursing staff
- D. A client who has histrionic personality disorder and seeks constant attention
Correct Answer: A
Rationale: Clients with borderline personality disorder (BPD) who act impulsively can be a significant safety concern. Impulsive behaviors in BPD can include self-harm, suicidal ideation, substance abuse, and other risky actions. These behaviors can pose immediate and severe threats to the client's safety and require close monitoring, intervention, and support.
A nurse is reinforcing teaching with a client about naltrexone. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will not experience alcohol withdrawal if I take this medication.
- B. The medication will allow me to gradually decrease my alcohol intake.
- C. If I drink alcohol with this medication, I will experience ringing in my ears.
- D. Taking this medication will reduce my cravings for alcohol.
Correct Answer: D
Rationale: This statement accurately reflects one of the primary effects of naltrexone. The medication helps reduce cravings for alcohol, making it easier for individuals to maintain abstinence and avoid relapse. By understanding this aspect of naltrexone, the client demonstrates a clear understanding of its purpose and use in alcohol dependence treatment.