Nokea
A nurse is beginning a therapeutic relationship with a client who has paranoid personality disorder. Which of the following strategies should the nurse plan to use?
- A. Demonstrate a neutral demeanor.
- B. Use an overly friendly approach.
- C. Ask the client why he is suspicious of others.
Correct Answer: A
Rationale: Demonstrating a neutral demeanor helps build trust with a client who has paranoid personality disorder. This non-threatening approach avoids triggering suspicion, fostering a therapeutic relationship.
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Nurses' Notes
0205: Client brought to the ED by police after being found wandering on the street. Client able to provide identity to police but not able to identify place or time. Family notified. Client confused and agitated. Appearance is disheveled. Mucous membranes dry. Lungs clear and equal, heart rhythm regular. During data collection, client states, "Can you ask that person to leave my room?" Client is pointing to an empty chair.
0415: Client's adult child arrived to the ED and went to client's room. Client identified family member. Client is pacing and agitated, and states, "I don't understand why I am here." Adult child asks nurse to talk outside of room and states, "I don't know why they are so confused. They are not normally like this." Adult child states client has past medical history of hypertension and alcohol-related cirrhosis. Upon returning to room, client voided 250 mL of dark yellow, cloudy urine.
Vital Signs
0200:
• Temperature: 38.6°C (101.5°F)
• Heart rate: 104/min
• Respiratory rate: 18/min
• Blood pressure: 158/96 mm Hg
• Oxygen saturation: 98% on room air
0415:
• Temperature: 38.6°C (101.5°F)
• Heart rate: 108/min
• Respiratory rate: 20/min
• Blood pressure: 148/94 mm Hg
• Oxygen saturation: 98% on room air
Provider's Note
0230: Client diagnosis: delirium secondary to a urinary tract infection and dehydration. Will transfer client to medical-surgical unit.
Laboratory Results
0230:
• Serum toxicology screen: Alcohol: 60 mg/dL (80 to 200 mg/dL mild to moderate intoxication)
A nurse is caring for a 65-year-old male client in the emergency department (ED).For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.
- A. Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion.
- B. Administer lorazepam.
- C. Initiate 1:1 supervision.
- D. Administer acyclovir.
Correct Answer: A,B,C
Rationale: IV fluids address dehydration, lorazepam manages agitation or withdrawal, and 1:1 supervision ensures safety due to delirium. Acyclovir is unexpected as no viral infection is indicated.
A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide. Which of the following findings should the nurse identify as a risk factor for suicide?
- A. Currently married.
- B. Access to guns in the home.
- C. Terminal liver cancer.
- D. Alcohol use disorder.
Correct Answer: B,C,D
Rationale: Access to guns in the home, terminal liver cancer, and alcohol use disorder are significant risk factors for suicide. Guns increase lethality, terminal illness causes distress, and alcohol impairs judgment and increases impulsivity, all elevating suicide risk.
A nurse is contributing to the plan of care for a client who has acute delirium. Which of the following interventions should the nurse include in the plan of care?
- A. Limit the client's need to make decisions.
- B. Discourage visitation from the client's family.
- C. Keep the client's room dark at night.
- D. Provide a high-stimulation environment for the client.
Correct Answer: A
Rationale: Limiting the client's need to make decisions helps reduce stress and confusion, which can exacerbate symptoms of delirium. Simplifying choices and providing a structured environment can aid in orientation and reduce cognitive overload.
A nurse is collecting data from an older adult client who was admitted with heart failure. The nurse should report which of the following findings to the provider as an indication of delirium?
- A. Fluctuating level of orientation.
- B. Consistent state of depression.
- C. Demonstrates obsessive behaviors.
- D. Short-term memory loss.
Correct Answer: A
Rationale: A fluctuating level of orientation is a hallmark sign of delirium. Delirium is characterized by an acute and fluctuating course of altered mental status, including changes in attention and cognition, distinguishing it from depression or dementia.
A nurse is caring for an adolescent who was recently sexually assaulted. Which of the following statements by the adolescent's guardian represents the presence of a positive support system?
- A. I can encourage my child to think about what they did that allowed this event to happen.
- B. I anticipate that my child will feel some self-blame.
- C. I should encourage my child to focus solely on the future.
- D. I will have to do all I can to monitor my child's relationships.
Correct Answer: D
Rationale: Actively monitoring the adolescent's relationships can demonstrate vigilance and support, helping to create a safe environment for recovery. This shows a proactive, protective stance, indicative of a positive support system.