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A nurse is caring for a client who is receiving treatment for alcohol withdrawal. Which of the following findings is the highest priority?
- A. Vitamin deficiency
- B. Diaphoresis
- C. Tremors
- D. Visual hallucinations
Correct Answer: D
Rationale: The correct answer is D: Visual hallucinations. Visual hallucinations in a client undergoing alcohol withdrawal indicate severe withdrawal symptoms and potential progression to delirium tremens, a life-threatening condition. Addressing visual hallucinations promptly is crucial to prevent harm or injury to the client. Vitamin deficiency (choice A), diaphoresis (choice B), and tremors (choice C) are common symptoms of alcohol withdrawal but are not as immediately life-threatening as visual hallucinations. Therefore, addressing visual hallucinations takes priority over these symptoms.
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A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions is the highest priority?
- A. Protecting the client from injury.
- B. Determining the cause of the client’s anxiety.
- C. Ensuring that the client feels safe.
- D. Identifying the client’s coping skills.
Correct Answer: A
Rationale: The correct answer is A: Protecting the client from injury. This is the highest priority because ensuring the client's physical safety takes precedence in a crisis situation. If the client is at risk of harming themselves or others, immediate action must be taken to prevent injury. Determining the cause of anxiety, ensuring the client feels safe, and identifying coping skills are important but secondary priorities once the client's safety is assured. In a crisis situation, physical safety is paramount before addressing underlying causes or providing emotional support.
A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?
- A. "It sounds like you’re having a difficult time."
- B. "Have you talked to your parents about this yet?"
- C. "Why do you think you are so anxious?"
- D. "How long has this been going on?"
Correct Answer: A
Rationale: The correct answer is A: "It sounds like you’re having a difficult time." This response shows empathy and validation towards the client's feelings, which can help build rapport and trust. It acknowledges the client's emotions without making assumptions or judgments. It opens up the conversation for the client to further express their concerns and feelings.
Option B is incorrect because it assumes the client has not talked to their parents yet, which may not be the case and can invalidate the client's feelings. Option C is incorrect as it puts the client on the spot and may come off as confrontational. Option D is incorrect as it focuses on the duration rather than addressing the client's current emotional state.
A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?
- A. Prepare for gastric lavage due to an extremely elevated lithium level.
- B. Administer the morning dose of lithium.
- C. Check the client's medication record to assess whether the client has been refusing her lithium.
- D. Hold the medication and assess for early manifestations of toxicity.
Correct Answer: B
Rationale: A lithium level of 1.0 mEq/L is within the therapeutic range (0.6-1.2 mEq/L).
A nurse on an inpatient mental health unit is caring for a client who has major depressive disorder and malnutrition. Which of the following actions should the nurse take to improve the client's nutritional status?
- A. Enroll the client in a nutritional class on the unit.
- B. Weigh the client at the same time every morning.
- C. Ask the provider to arrange a consultation with the facility chaplain.
- D. Sit with the client during meals and snacks.
Correct Answer: D
Rationale: The correct answer is D: Sit with the client during meals and snacks. This option promotes a therapeutic relationship, encourages the client to eat, and provides emotional support. By sitting with the client, the nurse can monitor food intake, address any eating difficulties, and offer encouragement. This approach helps the client feel supported and valued, which can positively impact their nutritional intake.
Choice A is incorrect as a nutritional class may not address the client's immediate needs. Choice B is incorrect as weighing the client daily does not directly improve their nutritional status. Choice C is incorrect as involving the chaplain may not address the nutritional needs of the client.
A nurse is discussing obsessive-compulsive disorder (OCD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the underlying reason clients with OCD perform ritualistic behaviors?
- A. "The ritualistic behavior provides sexual satisfaction."
- B. "The client performs ritualistic behavior to boost self-esteem."
- C. "The ritualistic behavior temporarily relieves anxiety."
- D. "The client performs ritualistic behavior to decrease feelings of shame."
Correct Answer: C
Rationale: OCD rituals are performed to reduce anxiety, even if they are illogical or excessive.