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A nurse is caring for a client who attacked one of her friends and is admitted to the psychiatric unit. Which of the following actions should the nurse take first?
- A. Establish a client relationship.
- B. Explain to the client that the behavior was unacceptable.
- C. Explore the truth of the client’s statements.
- D. Set behavioral limits for the client.
Correct Answer: D
Rationale: Setting behavioral limits helps establish expectations for the client’s conduct in the unit.
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A nurse is caring for a client who has bipolar disorder. The client states, "I feel like Superman. I can do anything. I can fly home today and then become a U.S. Senator.” Which of the following findings is this client exhibiting?
- A. Flight of ideas
- B. Grandiosity
- C. Impaired reality testing
- D. Depersonalization
Correct Answer: B
Rationale: The correct answer is B: Grandiosity. The client's belief that they can do anything, like flying and becoming a U.S. Senator, reflects grandiosity, a symptom of bipolar disorder's manic phase. This is characterized by an inflated sense of self-importance and abilities. Flight of ideas (A) is a rapid shifting of thoughts, not seen in this scenario. Impaired reality testing (C) involves difficulty distinguishing between reality and fantasy; this client is not questioning reality. Depersonalization (D) is feeling detached from oneself, not demonstrated here.
A nurse in an acute care facility is admitting an older adult client who has dementia due to Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is finding it more and more difficult to care for his wife. Which of the following interventions is the nurse’s priority?
- A. Recommend that the partner place the client in a long-term care facility.
- B. Suggest that the partner see a counselor to help him cope with his exhaustion.
- C. Ask the partner to talk about his difficulties in caring for the client.
- D. Tell the partner to call a family meeting to get help.
Correct Answer: C
Rationale: Rationale: The correct answer is C - Ask the partner to talk about his difficulties in caring for the client. This is the priority intervention as it allows the nurse to assess the partner's needs, provide emotional support, and gather information to develop a plan for support. By actively listening to the partner's concerns, the nurse can address immediate issues and provide resources for assistance. Other options (A) recommending long-term care, (B) suggesting counseling, and (D) calling a family meeting are important but not the priority as they do not directly address the partner's immediate emotional and practical needs. It is essential to prioritize addressing the partner's exhaustion and emotional well-being to ensure holistic care for both the client with dementia and their caregiver.
A nurse in an emergency department is caring for an adolescent client who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take?
- A. Discuss self-defense techniques with the client.
- B. Inform the client that photographs of injuries are required for a police report.
- C. Ask the client to describe the situation.
- D. Give the client a bed bath prior to physical examination.
Correct Answer: C
Rationale: Allowing the client to provide details at their own pace fosters a sense of control.
A nurse is assessing a parent who lost a 12-year-old child in a car crash 2 years ago. Which of the following findings indicates the client is exhibiting manifestations of prolonged grieving?
- A. Leaves the child's room exactly as it was before the loss
- B. Volunteers at a local children's hospital
- C. Talks about the child in the past tense
- D. Visits the child's grave every week after worship services
Correct Answer: A
Rationale: In prolonged grief, individuals may struggle to move forward and avoid changing their environment.
A nurse is caring for an adolescent who has a history of violent behavior and has asked the nurse to keep confidential information about the desire to kill several classmates and a school teacher. Which of the following responses by the nurse is appropriate to give?
- A. "Because you are a minor, I have to share any information that I feel is important with your parents."
- B. "I cannot promise that. I must share this information with other members of the team who are responsible for planning your care."
- C. "I will not violate our nurse-client relationship. The information we discuss will remain confidential between us."
- D. "I can see that you trust me, but you should share those feelings with your psychiatrist, not me."
Correct Answer: B
Rationale: Duty to warn applies when a client expresses intent to harm others, requiring disclosure to the care team.