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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 teaching a client who has schizophrenia about the adverse effects of clozapine. Which of the following side effects should the nurse include in the teaching?
- A. Increased salivation
- B. Tardive dyskinesia
- C. Hypertension
- D. Photosensitivity
Correct Answer: B
Rationale: The correct answer is B: Tardive dyskinesia. Clozapine can lead to this side effect, which is characterized by involuntary movements of the face and body. This is important to include in teaching as it can be a serious and potentially irreversible effect of the medication. Increased salivation (choice A) is not a common side effect of clozapine. Hypertension (choice C) is not typically associated with clozapine use. Photosensitivity (choice D) is not a common side effect of clozapine. Overall, choice B is the correct answer as it aligns with the known side effects of clozapine in individuals with schizophrenia.
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 in a mental health facility is caring for a client who has borderline personality disorder. Which of the following should the nurse expect?
- A. Self-mutilation
- B. Pacing back and forth
- C. Preoccupation with details
- D. Disorganized speech
Correct Answer: A
Rationale: The correct answer is A: Self-mutilation. Individuals with borderline personality disorder often engage in self-harming behaviors as a way to cope with intense emotions or distress. This behavior is a common manifestation of the disorder and requires careful monitoring and intervention by the nurse.
Incorrect Choices:
B: Pacing back and forth - This behavior is more commonly associated with anxiety or agitation rather than specifically with borderline personality disorder.
C: Preoccupation with details - While individuals with borderline personality disorder may display perfectionistic tendencies, preoccupation with details is not a defining characteristic of the disorder.
D: Disorganized speech - Disorganized speech is more commonly seen in conditions such as schizophrenia, rather than borderline personality disorder.
A nurse is caring for a client in the emergency department who states she was beaten and sexually assaulted by her partner. After a rapid assessment, which of the following actions should the nurse plan to take next?
- A. Conduct a pregnancy test
- B. Request mental health consultation for the client
- C. Provide a trained advocate to stay with the client
- D. Offer prophylactic medication to prevent STI’s
- E. A client who describes having persistent feelings of anger about the hurricane.
Correct Answer: A
Rationale: The correct answer is A: Conduct a pregnancy test. This action is important to assess the client's risk of pregnancy resulting from the sexual assault. Pregnancy testing is crucial for timely decision-making regarding emergency contraception. This step is a priority in the care of a sexual assault survivor. It ensures appropriate medical intervention and support for the client's physical and emotional well-being.
Summary of other choices:
B: Requesting mental health consultation is important but not the immediate next step.
C: Providing a trained advocate is valuable for support but does not address the urgent medical needs of the client.
D: Offering prophylactic medication for STIs is important but not the immediate next step before assessing pregnancy risk.
E: This choice is unrelated to the situation described and should not be considered in this context.
A nurse is providing teaching to a client who has bipolar disorder and a new prescription for lithium. Which of the following instructions should the nurse include?
- A. Take lithium on an empty stomach
- B. Avoid consuming foods high in sodium
- C. Drink 2-3 liters of water daily
- D. Increase caffeine intake
Correct Answer: C
Rationale: The correct answer is C: Drink 2-3 liters of water daily. Lithium is a mood stabilizer that can cause dehydration. Drinking an adequate amount of water helps prevent lithium toxicity and maintain proper kidney function. Choice A is incorrect because lithium should be taken with food to reduce gastrointestinal side effects. Choice B is incorrect because limiting sodium intake is not directly related to lithium therapy. Choice D is incorrect as increasing caffeine intake can lead to dehydration and worsen lithium side effects.