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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.
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A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?
- A. Determining if the client has psychotic thinking
- B. Asking the client to identify the cause of the crisis
- C. Identifying the client's coping skills
- D. Identifying the client's support systems
Correct Answer: A
Rationale: The correct answer is A: Determining if the client has psychotic thinking. This is the highest priority because it directly addresses the client's immediate safety and well-being. Psychotic thinking can pose a significant risk to the client and others, requiring prompt intervention. Asking the client to identify the cause of the crisis (B), identifying coping skills (C), and support systems (D) are important but secondary to ensuring the client's safety. It is crucial to address any potential psychotic thinking first before delving into other aspects of the assessment.
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 teaching a newly licensed nurse about reporting suspected child abuse. Which of the following statements indicates an understanding by the newly licensed nurse?
- A. "Evidence must exist prior to reporting."
- B. "If the potential abuser commits to stopping the abuse, health care workers are not required to report it."
- C. "I don't want to defame someone if the report is false."
- D. "If suspicion of abuse exists, then reporting is mandatory."
Correct Answer: D
Rationale: The correct answer is D: "If suspicion of abuse exists, then reporting is mandatory." This statement is correct because as a healthcare professional, it is crucial to report any suspicion of child abuse to protect the child's safety. Reporting is mandatory to ensure that appropriate actions are taken to investigate and prevent harm to the child.
A: "Evidence must exist prior to reporting." - This statement is incorrect because suspicion alone is enough to trigger reporting, and waiting for evidence may delay intervention and put the child at risk.
B: "If the potential abuser commits to stopping the abuse, health care workers are not required to report it." - This statement is incorrect as it is the responsibility of healthcare workers to report suspected abuse regardless of promises made by the potential abuser.
C: "I don't want to defame someone if the report is false." - This statement is incorrect because the focus should be on the safety and well-being of the child, and reporting suspicions of abuse is not about def
A charge nurse is discussing suicide interventions with nursing staff. Which of the following should the nurse identify as an example of secondary intervention?
- A. Providing support for family and friends following a suicide.
- B. Identifying individuals who are at higher risk for attempting suicide.
- C. Recognizing the warning signs of suicide.
- D. Performing life-saving measures following a suicide attempt.
Correct Answer: D
Rationale: Secondary intervention involves direct care during a suicide crisis, such as life-saving measures.
A nurse is caring for several clients who have mental health disorders at an assisted-living facility. Which of the following clients should the nurse determine needs to be seen by a provider immediately?
- A. A client who is taking olanzapine and experiences dizziness when first standing up
- B. A client who is taking chlorpromazine and reports vomiting twice
- C. A client who is taking thioridazine and has daytime drowsiness
- D. A client who is taking clozapine and has flu-like manifestations
Correct Answer: D
Rationale: The correct answer is D. Clozapine is associated with a serious side effect called agranulocytosis, which can manifest as flu-like symptoms such as fever, sore throat, and malaise. Agranulocytosis is a potentially life-threatening condition that requires immediate medical attention to prevent complications. Clients taking clozapine should be monitored closely for signs of infection. Choices A, B, and C describe common side effects of antipsychotic medications that are not typically considered emergencies. For example, dizziness upon standing (A), vomiting (B), and daytime drowsiness (C) are known side effects that may not require immediate medical attention unless severe or persistent. Therefore, the client taking clozapine with flu-like manifestations (D) should be seen by a provider immediately due to the potential seriousness of agranulocytosis.