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A nurse is caring for a client who has post-traumatic stress disorder (PTSD). Which of the following interventions should the nurse include in the plan of care?
- A. Encourage the client to discuss past trauma
- B. Provide a structured routine
- C. Discourage emotional expression
- D. Limit social interactions
Correct Answer: B
Rationale: The correct answer is B: Provide a structured routine. Individuals with PTSD often benefit from a predictable routine as it provides a sense of safety and control. This intervention helps regulate emotions and reduces anxiety by creating a stable environment. Encouraging the client to discuss past trauma (A) may worsen symptoms if the client is not ready. Discouraging emotional expression (C) can be harmful as it may lead to emotional suppression. Limiting social interactions (D) may increase feelings of isolation and exacerbate symptoms. It's important to prioritize stability and structure in the plan of care for clients with PTSD.
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A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following actions should the nurse take?
- A. Place the client in a group therapy session
- B. Rotate staff members who work with the client
- C. Encourage the client to participate in physical activities
- D. Distract the client with increased environmental stimuli
Correct Answer: C
Rationale: The correct answer is C: Encourage the client to participate in physical activities. Physical activities can help to channel the excess energy and agitation associated with manic episodes in bipolar disorder. Exercise can help reduce stress, improve mood, and promote better sleep patterns. Group therapy (A) may not be appropriate during a manic episode as the client may have difficulty focusing and could disrupt the session. Rotating staff members (B) could lead to inconsistency in care and may worsen the client's symptoms. Distracting the client with increased environmental stimuli (D) could exacerbate agitation and overstimulation. It is important to provide a structured and safe outlet for the client's energy, hence physical activities are the most appropriate intervention in this scenario.
A nurse is teaching the parent of a school-age child who has ADHD and a prescription for atomoxetine 40 mg daily. Which of the following information should the nurse include in the teaching?
- A. Expect the child to gain weight while taking this medication
- B. Crush the medication and mix it with 120 mL (4 oz) of juice
- C. Therapeutic effects will occur within 24 hr of starting treatment
- D. Administer the medication before the child goes to school in the morning
Correct Answer: D
Rationale: The correct answer is D: Administer the medication before the child goes to school in the morning. Atomoxetine is a non-stimulant medication used to treat ADHD. Administering it in the morning allows for optimal absorption and effectiveness during the school day. This helps in improving the child's focus and attention span in a learning environment. Additionally, taking the medication in the morning helps in minimizing potential side effects such as insomnia. Choices A, B, and C are incorrect because weight gain is not a common side effect of atomoxetine, crushing the medication can alter its effectiveness, and therapeutic effects usually take a few weeks to manifest, not within 24 hours.
A nurse is assessing a client who is experiencing alcohol withdrawal. Which of the following findings should the nurse expect?
- A. Bradycardia
- B. Visual hallucinations
- C. Hypotension
- D. Hyperactivity
Correct Answer: B
Rationale: The correct answer is B: Visual hallucinations. During alcohol withdrawal, the client may experience hallucinations due to the central nervous system's hyperexcitability. This symptom is typically seen within 12-24 hours of the last drink. Bradycardia (A) and hypotension (C) are less common in alcohol withdrawal; tachycardia and hypertension are more typical. Hyperactivity (D) is not a common symptom and is more likely to be seen in stimulant withdrawal.
A nurse is providing teaching to the daughter of an older client who has obsessive-compulsive disorder. Which of the following statements by the daughter indicates an understanding of the disorder?
- A. I will limit my mother’s clothing choices when she is getting dressed
- B. I will provide my mother with detailed instructions about how to perform self-care
- C. I will wake my mother up a couple of times in the night to check on her
- D. I will discourage my mother from talking about physical complaints
Correct Answer: B
Rationale: The correct answer is B: "I will provide my mother with detailed instructions about how to perform self-care." This statement indicates an understanding of obsessive-compulsive disorder (OCD) because individuals with OCD often struggle with performing daily tasks due to their obsessive thoughts and compulsive behaviors. By providing detailed instructions, the daughter is acknowledging the need for structured routines to help her mother manage her symptoms.
A: Limiting clothing choices does not address the underlying issues of OCD and may exacerbate anxiety.
C: Waking the mother up to check on her reinforces compulsions, which is counterproductive in treating OCD.
D: Discouraging the mother from talking about physical complaints does not address the core symptoms of OCD.
By choosing option B, the daughter shows insight into the importance of providing support and guidance in managing the challenges associated with OCD.
A nurse is caring for a client who has depression following a recent job loss. Which of the following questions should the nurse ask to assess the client’s personal coping skills?
- A. How does this situation affect your life?
- B. Do you see your current situation affecting your future?
- C. Can you describe how you are currently feeling?
- D. How have you dealt with similar situations in the past?
Correct Answer: D
Rationale: The correct answer is D: How have you dealt with similar situations in the past? This question assesses the client's personal coping skills by exploring their past strategies for managing challenging situations. By understanding their previous coping mechanisms, the nurse can identify effective approaches to support the client in managing their current depression.
A: How does this situation affect your life? - This question focuses on the impact of the current situation but does not directly assess the client's coping skills.
B: Do you see your current situation affecting your future? - This question explores the client's perspective on the influence of the situation on their future, but it does not specifically address coping skills.
C: Can you describe how you are currently feeling? - This question evaluates the client's emotional state but does not directly assess coping skills.