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A nurse is caring for a client whose partner died five years ago. The nurse recognizes that which of the following findings would indicate the client is experiencing maladaptive grief?
- A. The client meets his daughter for dinner every week.
- B. The client joined a bowling league 2 months ago.
- C. The client exercises at a local health facility 3 days each week.
- D. The client has kept his partner's closet untouched since her death.
Correct Answer: D
Rationale: The correct answer is D because keeping the partner's closet untouched after five years indicates a lack of acceptance and inability to move forward in the grieving process, suggesting maladaptive grief. Choice A shows social support, B reflects engagement in a new activity, and C indicates a healthy coping mechanism through exercise.
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A nurse is providing teaching to a client diagnosed with schizophrenia and is prescribed haloperidol (Haldol). Which of the following information should the nurse include in the teaching?
- A. This medication will decrease your symptoms of OCD.
- B. This medication may cause excessive salivation.
- C. You can stop taking the medication if the side effects are bothersome.
- D. You may experience dizziness upon standing while taking this medication.
Correct Answer: D
Rationale: The correct answer is D: You may experience dizziness upon standing while taking this medication. This is important information to include because haloperidol can cause orthostatic hypotension, leading to dizziness upon standing. This is a common side effect that the client should be aware of to prevent falls. Option A is incorrect because haloperidol is not used to treat OCD. Option B is incorrect because excessive salivation is not a common side effect of haloperidol. Option C is incorrect because it is crucial not to stop taking antipsychotic medications abruptly without consulting a healthcare provider.
A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply.)
- A. Weigh the client every 3 to 4 days.
- B. Discourage the client from taking a nap during the day.
- C. Monitor vital signs throughout the day.
- D. Offer nutritional foods to the client every 2 hours.
- E. Maintain an environment with low stimuli.
Correct Answer: B,C,D,E
Rationale: The correct interventions are B, C, D, and E. B: Discouraging naps helps regulate sleep patterns in mania. C: Monitoring vital signs is crucial due to potential physical risks. D: Offering frequent, nutritional foods helps stabilize energy levels. E: Low-stimuli environment reduces agitation. A is incorrect as frequent weighing may not be necessary. F and G are not provided but would be incorrect if they do not align with managing mania symptoms.
A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting,and now the client is pacing up and down the hallways of the unit. Which of the following actions should the nurse take?
- A. Instruct the client to sit down and stop pacing.
- B. Allow the client to pace alone until physically tired.
- C. Have a staff member escort the client to her room.
- D. Walk with the client at a gradually slower pace.
Correct Answer: D
Rationale: Walking with the client calmly reduces anxiety while providing support.
A nurse is caring for a client who is refusing to attend group therapy. The client states,I don't know why you think I need therapy. I am fine without it. Which of the following responses by the nurse indicates a therapeutic response?
- A. I understand that you feel like you don't need it; however, the provider thinks it will help.
- B. You don't feel like group therapy is for you. Tell me more about what you know about group therapy.
- C. I am not saying that you need therapy, but I am sure it will help you.
- D. You don't have to be afraid to go. Our therapists are very understanding.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Option B demonstrates therapeutic communication by showing empathy and understanding towards the client's feelings and inviting further discussion. By encouraging the client to express their thoughts on group therapy, the nurse opens up a dialogue to explore the client's beliefs and concerns, fostering trust and rapport. This approach respects the client's autonomy and promotes client-centered care.
Summary of Incorrect Choices:
A: This response dismisses the client's feelings and focuses on the provider's opinion, potentially alienating the client and not addressing their concerns.
C: This response minimizes the client's feelings and imposes the nurse's beliefs, which may lead to resistance and hinder the therapeutic relationship.
D: This response invalidates the client's emotions by assuming fear as the underlying issue and may create defensiveness rather than addressing the client's actual concerns.
A nurse is condu,a client diagnosed with schizophrenia jumps up and runs out while yelling You are all making fun of me. The nurse recognizes that the client is displaying which of the following behaviors?cting a group therapy meeting and shares a humorous story. When the group laughs at the story
- A. Flight of ideas
- B. Erotomania
- C. Grandeur
- D. Ideas of reference
Correct Answer: D
Rationale: The correct answer is D: Ideas of reference. This behavior is exhibited when a person believes that neutral events or actions are directed at them personally. In this scenario, the client with schizophrenia perceives others are making fun of them when that may not be the case. This demonstrates a misinterpretation of external stimuli. Flight of ideas (A) refers to rapidly shifting from one idea to another. Erotomania (B) is a delusion where someone believes another person is in love with them. Grandeur (C) involves exaggerated beliefs of one's importance or power.