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A nurse is caring for a client who has an anxiety disorder and reports ongoing difficulty sleeping at night. Which of the following recommendations should the nurse make?
- A. Drink 5 ounces of red wine roughly 30 minutes before bed.
- B. Limit caffeine to one or two servings during daytime hours.
- C. Exercise 1 hour before bedtime.
- D. Stay in bed for 1 hour before getting up if you are unable to sleep.
Correct Answer: B
Rationale: Limiting caffeine intake to one or two servings during daytime hours is a beneficial recommendation for improving sleep. Caffeine is a stimulant that can interfere with the ability to fall asleep and stay asleep. By reducing caffeine consumption and avoiding it in the late afternoon and evening, individuals can enhance their chances of achieving restful sleep.
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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 in a mental health facility is contributing to the plan of care for a new client. Which of the following actions should the nurse plan to include in the working phase of the nurse-client relationship?
- A. Determine whether the client's goals are met.
- B. Collect data about the client's current health status.
- C. Provide the client with information on problem-solving.
- D. Establish a regular meeting time with the client.
Correct Answer: C
Rationale: Providing the client with information on problem-solving is an essential component of the working phase of the nurse-client relationship. During this phase, the nurse and client work collaboratively to address issues, develop coping strategies, and implement interventions aimed at improving the client's mental health.
A nurse is reinforcing teaching with a client who has a new prescription for a nicotine transdermal system. Which of the following statements should the nurse make?
- A. A decrease in appetite is expected when beginning treatment.
- B. Using this medication will help minimize symptoms of withdrawal.
- C. Expect to stop smoking immediately after starting this medication.
- D. Apply a new patch every 4 hours until your cravings diminish.
Correct Answer: B
Rationale: Nicotine replacement therapy, including the nicotine transdermal system, is designed to help minimize symptoms of nicotine withdrawal. These symptoms can include cravings, irritability, anxiety, and difficulty concentrating. By providing a controlled release of nicotine, the transdermal system helps reduce the intensity of withdrawal symptoms and supports the quitting process.
A nurse is assisting with the involuntary admission of a client who has an anxiety disorder and is unable to meet their basic physical needs. Which of the following statements should the nurse make to the client?
- A. You have the right to refuse medications prescribed during your stay.
- B. Your admission status allows you to leave the facility at any time.
- C. Your health care team will review your admission status in 90 days.
- D. You will automatically have a legal guardian appointed during this admission.
Correct Answer: A
Rationale: Clients who are involuntarily admitted to a psychiatric facility retain certain rights, including the right to refuse medications. This is an important part of patient autonomy and informed consent. Even though the client is involuntarily admitted, they must still be provided with information about their treatment options and have the right to make decisions about their medications unless there is a court order stating otherwise.
A nurse is caring for a client who is combative and requires wrist restraints. Which of the following actions should the nurse take?
- A. Use a quick-release tie to restrain the client.
- B. Renew the restraint prescription every 48 hr.
- C. Attach the restraints to the side rail of the client's bed.
- D. Maintain 1 fingerbreadth between the restraint and the client's skin.
Correct Answer: A
Rationale: Using a quick-release tie for restraints ensures that the nurse can quickly and easily release the client in case of an emergency. Quick-release ties are designed to provide safety and convenience, allowing healthcare providers to promptly respond to the client's needs without compromising safety.