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A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates understanding of a relapse prevention plan?
- A. "I can remember when my hallucinations first began."
- B. "I know which of my hallucinations trigger a relapse."
- C. "I record the number of hallucinations I have each day."
- D. "I will read as much information as I can about schizophrenia."
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Option B, "I know which of my hallucinations trigger a relapse," indicates the client's understanding of identifying triggers for relapse. This awareness is crucial in preventing relapse by avoiding or managing triggers effectively. Understanding personal triggers helps the client take proactive steps to maintain stability.
Incorrect Choices:
A: "I can remember when my hallucinations first began." This statement does not demonstrate a proactive plan for relapse prevention.
C: "I record the number of hallucinations I have each day." Monitoring hallucinations is important but does not necessarily indicate understanding of relapse prevention.
D: "I will read as much information as I can about schizophrenia." While education is vital, it does not directly address relapse prevention strategies.
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A newly admitted client with obsessive-compulsive disorder (OCD) is performing ritualistic behaviors. What should the nurse do first?
- A. Discuss alternative coping strategies
- B. Identify precipitating factors for rituals
- C. Instruct on relaxation techniques
- D. Provide a structured activity schedule
Correct Answer: B
Rationale: The correct answer is B: Identify precipitating factors for rituals. This is the first step because understanding what triggers the client's rituals is crucial in developing an effective treatment plan. By identifying these factors, the nurse can address the root cause of the behavior and work towards reducing or eliminating it. Discussing coping strategies (A) may come later once the triggers are identified. Instructing on relaxation techniques (C) and providing a structured activity schedule (D) are helpful interventions but addressing the triggers takes precedence.
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 nurse in a mental health facility is preparing to interview a client who has schizophrenia. Which of the following actions should the nurse take?
- A. Sit on the other side of a table from the client.
- B. Place the client in a chair higher than the nurse.
- C. Start the interview with a question the client can answer with “yes” or "no."
- D. Sit beside the client rather than facing him.
Correct Answer: C
Rationale: The correct answer is C: Start the interview with a question the client can answer with “yes” or "no." This approach is recommended for clients with schizophrenia to establish rapport and ease anxiety. It allows the client to engage in a simple way, reducing the pressure of providing complex answers. Sitting on the other side of a table (A) may create a barrier, placing the client in a higher chair (B) may be perceived as intimidating, and sitting beside the client (D) may invade personal space. The other choices do not promote effective communication or rapport-building.
A nurse in an acute care facility is admitting an older adult client who has dementia due to Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is finding it more and more difficult to care for his wife. Which of the following interventions is the nurse’s priority?
- A. Recommend that the partner place the client in a long-term care facility.
- B. Suggest that the partner see a counselor to help him cope with his exhaustion.
- C. Ask the partner to talk about his difficulties in caring for the client.
- D. Tell the partner to call a family meeting to get help.
Correct Answer: C
Rationale: Rationale: The correct answer is C - Ask the partner to talk about his difficulties in caring for the client. This is the priority intervention as it allows the nurse to assess the partner's needs, provide emotional support, and gather information to develop a plan for support. By actively listening to the partner's concerns, the nurse can address immediate issues and provide resources for assistance. Other options (A) recommending long-term care, (B) suggesting counseling, and (D) calling a family meeting are important but not the priority as they do not directly address the partner's immediate emotional and practical needs. It is essential to prioritize addressing the partner's exhaustion and emotional well-being to ensure holistic care for both the client with dementia and their caregiver.
A nurse manager is providing staff education about working with clients who have a history of anger and aggression. Which of the following information should the nurse include in the teaching? (Select all that apply.)
- A. Avoid wearing necklaces during client care.
- B. Know the layout of the facility.
- C. Stand directly in front of the client when talking.
- D. Bring security with you for all client interactions.
- E. Provide immediate verbal feedback for escalating behavior.
Correct Answer: A, B, E
Rationale: The correct answers are A, B, and E. A: Wearing necklaces can be used as a weapon or trigger aggressive behavior. B: Knowing the facility layout helps in planning safe exits during an escalating situation. E: Providing immediate verbal feedback can help de-escalate aggressive behavior. C: Standing directly in front of the client can be confrontational. D: Bringing security for all interactions may escalate tension unnecessarily.