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A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client?
- A. Watching a video with a group in the day room
- B. Walking with the nurse in the courtyard
- C. Participating in a basketball game in the gym
- D. Joining a group discussion about a local election
Correct Answer: B
Rationale: The correct answer is B: Walking with the nurse in the courtyard. During the manic phase, individuals with bipolar disorder may have high energy levels and increased impulsivity. Walking in the courtyard with the nurse provides a safe outlet for physical activity and helps to channel excess energy in a constructive manner. This activity also allows for one-on-one interaction, which can help the client focus and reduce boredom. Other options like watching a video with a group or participating in a basketball game may be too stimulating and could exacerbate manic symptoms. Joining a group discussion about a local election might be overwhelming and less effective in managing the client's energy level and attention.
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A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?
- A. The partner has placed locks at the top of the doors leading to the outside.
- B. The partner has hired a house cleaner.
- C. The partner has lost 20 lb in the past 2 months.
- D. The partner redirects the client when the client is frustrated.
Correct Answer: C
Rationale: The correct answer is C because the partner losing 20 lb in the past 2 months indicates caregiver role strain. Significant weight loss can be a sign of stress, neglecting self-care, and being overwhelmed by caregiving responsibilities. This observation suggests that the partner may not be prioritizing their own well-being while caring for the client with Alzheimer's disease.
Choice A is incorrect because placing locks at the top of doors is a safety measure commonly taken to prevent the client with Alzheimer's disease from wandering outside unsupervised. Choice B is incorrect as hiring a house cleaner can be a practical solution to manage household tasks and does not necessarily indicate caregiver role strain. Choice D is incorrect because redirecting the client when frustrated is a positive caregiving technique to manage challenging behaviors.
A nurse is caring for a client who is hospitalized for the treatment of severe depression. Which of the following nursing approaches is therapeutic to include in the client's plan of care?
- A. Encouraging decision-making
- B. Playing a game of chess with the client
- C. Giving the client choices of activities
- D. Spending time sitting with the client
Correct Answer: D
Rationale: The correct answer is D: Spending time sitting with the client. This approach is therapeutic as it promotes a sense of companionship, support, and comfort for the client. By being present and engaged in the moment, the nurse can establish trust and demonstrate empathy towards the client, which are crucial in the treatment of severe depression. This approach also provides an opportunity for the client to express their feelings and thoughts in a safe and non-judgmental environment.
Choice A, encouraging decision-making, may overwhelm the client who is dealing with severe depression and may exacerbate their feelings of helplessness. Choice B, playing a game of chess, may be too stimulating or competitive for the client in this vulnerable state. Choice C, giving the client choices of activities, may add unnecessary pressure and decision-making burden on the client. Overall, spending time sitting with the client is the most appropriate and therapeutic nursing approach in this scenario.
A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder. Which of the following interventions should the nurse identify as the priority?
- A. Helping the client identify positive personality traits
- B. Providing for adequate hydration and rest
- C. Confronting the use of denial and other defense mechanisms
- D. Educating the client about the consequences of alcohol misuse
Correct Answer: B
Rationale: The correct answer is B: Providing for adequate hydration and rest. The priority in caring for a client with alcohol use disorder is addressing physical needs like hydration and rest to manage withdrawal symptoms and prevent complications. Hydration helps prevent dehydration and electrolyte imbalances, while rest supports the body's healing process. Choices A, C, and D focus on psychological aspects, which are important but secondary to addressing immediate physical needs. Helping the client identify positive traits can come later in therapy, confronting denial and defense mechanisms can be addressed once the client is stabilized, and educating about consequences is important but not as urgent as ensuring hydration and rest.
A client awaiting surgery expresses fear of having cancer. Which response by the nurse is most appropriate?
- A. "Why do you think you have cancer?"
- B. "I don't see any reason for you to worry."
- C. "That's something to discuss with your provider."
- D. "I hear that you are concerned about this."
Correct Answer: D
Rationale: The correct answer is D because it acknowledges the client's feelings and shows empathy. By saying, "I hear that you are concerned about this," the nurse validates the client's emotions and creates a supportive environment. Choice A is incorrect as it may come off as dismissive. Choice B is inappropriate as it invalidates the client's fear. Choice C passes the responsibility back to the client's provider instead of addressing the immediate concern.
A nurse is caring for a client who has schizophrenia. The client states, "The government is forcing thoughts into my brain through satellites." The nurse should document that the client is experiencing which of the following types of delusions?
- A. Persecution
- B. Erotomanic
- C. Somatic
Correct Answer: A
Rationale: Persecutory delusions involve irrational beliefs that one is being targeted or harmed by external forces.