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A nurse is caring for a client who has bipolar disorder and is running around the unit asking people to dance with her. Which of the following interventions should the nurse take?
- A. Turn on a dance video so the client can burn off excess energy.
- B. Offer the client a low-calorie snack in return for stopping the behavior.
- C. Walk the client outside and sit with her in the garden area.
- D. Observe the client closely for the development of aggressive behavior.
Correct Answer: C
Rationale: The correct answer is C: Walk the client outside and sit with her in the garden area. This intervention helps the client to redirect their energy in a positive and calming manner. Being outdoors can provide a change of environment, fresh air, and can help the client feel more grounded. It also offers a distraction from the impulsive behavior and promotes relaxation. Turning on a dance video (choice A) may further stimulate the client's behavior rather than calming them down. Offering a snack (choice B) may reinforce the behavior and is not addressing the underlying issue. Observing for aggressive behavior (choice D) is important but does not actively address the client's current behavior.
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A nurse is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse identify as the primary cause of liver cirrhosis?
- A. Alcohol
- B. Caffeine
- C. Cocaine
- D. Inhalants
Correct Answer: A
Rationale: Chronic alcohol use is the leading cause of liver cirrhosis due to its toxic effects on liver cells.
A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?
- A. Experiencing diarrhea
- B. Exercising moderately
- C. Increasing sodium intake
- D. Drinking green tea
Correct Answer: A
Rationale: The correct answer is A: Experiencing diarrhea. Diarrhea can lead to dehydration and electrolyte imbalances, which can increase lithium levels in the blood and cause toxicity. This is because lithium is primarily excreted by the kidneys, and dehydration can impair its elimination. Options B, C, and D are incorrect because moderate exercise, increasing sodium intake, and drinking green tea are not known to directly cause lithium toxicity. In fact, maintaining adequate hydration and a balanced diet with normal sodium intake can help prevent lithium toxicity.
A nurse is caring for a client who has major depressive disorder (MDD). Which of the following findings should the nurse expect?
- A. Significant change in weight
- B. Hyperexcitability
- C. Exaggerated response to stimuli
- D. Attention-seeking behavior
Correct Answer: A
Rationale: The correct answer is A: Significant change in weight. In major depressive disorder (MDD), clients commonly experience appetite changes, leading to weight gain or weight loss. This is due to disturbances in their eating patterns. Weight changes can be a result of decreased interest in food or emotional eating. This is a key symptom to monitor in clients with MDD. Hyperexcitability (B), exaggerated response to stimuli (C), and attention-seeking behavior (D) are not typical findings in clients with MDD. Hyperexcitability and exaggerated response to stimuli are more often associated with conditions like anxiety disorders, while attention-seeking behavior is more commonly seen in personality disorders.
A charge nurse is preparing an educational session about addictive disorders for nursing staff. Which of the following should the nurse include as an etiological factor of addictive disorders? (Select all that apply.)
- A. Low self-esteem
- B. Family history of addiction
- C. Personality disorders
- D. Asian ethnicity
Correct Answer: A, B, C
Rationale: Low self-esteem, family history, and personality disorders are risk factors for addiction. Ethnicity is not a primary factor.
A nurse is caring for an adolescent who is experiencing indications of depression. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Irritability
- B. Euphoria
- C. Chronic pain
- D. Social withdrawal
- E. Changes in appetite
Correct Answer: A, C, D, E
Rationale: Depression in adolescents often presents with irritability, physical complaints (chronic pain), social withdrawal, and appetite changes.