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A nurse is caring for a client who reports bilateral knee pain after hiking this past weekend in the mountains on rough ground. He says he is concerned because his cousin died from bone cancer recently. Which of the following actions should the nurse take?
- A. Tell the client that it is unlikely that he has bone cancer.
- B. Ask the client why he thinks the pain isn't a result of hiking.
- C. Suggest genetic testing so the client can understand his risks.
- D. Explain that the provider will see him and determine a course of action.
Correct Answer: D
Rationale: The nurse should provide reassurance while ensuring proper medical evaluation.
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A nurse in an acute mental health facility is creating a plan of care for a new client who has histrionic personality disorder. Which of the following is the priority intervention for the nurse to make?
- A. Promote appropriate behavior during group therapy sessions.
- B. Encourage client input in the treatment plan.
- C. Communicate with the client using concrete language.
- D. Demonstrate assertive behavior.
Correct Answer: A
Rationale: The correct answer is A: Promote appropriate behavior during group therapy sessions. For a client with histrionic personality disorder, the priority intervention is to establish boundaries and promote appropriate behavior to ensure a therapeutic environment. This is crucial in managing attention-seeking behaviors and maintaining focus on the therapeutic goals. Encouraging client input in the treatment plan (B) is important but not the priority at this stage. Communicating with concrete language (C) may be helpful but does not address the immediate need for behavior management. Demonstrating assertive behavior (D) is not the priority as it may escalate the situation.
A nurse is caring for a new client who exhibits manifestations of a major depressive episode. The provider states that she wants to rule out medical conditions that could also be linked to the findings. The nurse should expect diagnostic testing for which of the following medical conditions?
- A. Pancreatitis
- B. Cholecystitis
- C. Tuberculosis
- D. Hypothyroidism
Correct Answer: D
Rationale: The correct answer is D: Hypothyroidism. Major depressive episodes can be a symptom of hypothyroidism due to the impact of thyroid hormones on mood regulation. Diagnostic testing for hypothyroidism typically includes measuring levels of thyroid-stimulating hormone (TSH) and free thyroxine (T4). Pancreatitis (A) and cholecystitis (B) are conditions primarily related to the gastrointestinal system and do not typically present with depressive symptoms. Tuberculosis (C) is an infectious disease affecting the lungs and other organs, but it does not directly cause major depressive episodes. Therefore, ruling out hypothyroidism through diagnostic testing is the most relevant in this case.
A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (Select all that apply.)
- A. Grooming
- B. Long-term memory
- C. Support systems
- D. Affect
- E. Presence of pain
Correct Answer: A, B, D
Rationale: The correct choices for the nurse to include in the MSE for a client with dementia are A, B, and D. Grooming is important to assess the client's self-care ability, which can be impacted by dementia. Long-term memory is essential in evaluating cognitive decline typically seen in dementia. Affect assessment helps determine emotional responses and can indicate changes in mood associated with dementia. Support systems (choice C) are not typically part of the MSE but are relevant for treatment planning. Presence of pain (choice E) is important but not a traditional component of a mental status examination.
A nurse is caring for a client who has a mental illness. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?
- A. Encouraging client feedback about satisfaction with the facility experience
- B. Explaining unit rules and policies regarding unacceptable behaviors
- C. Supporting the client’s wish to refuse prescribed medications
- D. Making sure the client understands expectations for participation
Correct Answer: C
Rationale: The correct answer is C: Supporting the client’s wish to refuse prescribed medications. Autonomy refers to the client's right to make their own decisions about their care. By supporting the client's wish to refuse medications, the nurse is respecting the client's autonomy and right to make decisions about their treatment. This empowers the client to have control over their own healthcare decisions.
Explanation for incorrect choices:
A: Encouraging client feedback about satisfaction with the facility experience - This choice relates to client satisfaction but does not directly address autonomy.
B: Explaining unit rules and policies regarding unacceptable behaviors - This choice focuses on rules and policies, not autonomy.
D: Making sure the client understands expectations for participation - This choice is about ensuring understanding, not necessarily autonomy.
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.