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A nurse is caring for a client with Alzheimer’s disease. Which of the following actions should the nurse take?
- A. Seat the client at a dining table with six or more residents
- B. Provide the client with several choices for meal selection
- C. Give complete directions before starting client care
- D. Use symbols to assist the client in locating rooms
Correct Answer: D
Rationale: The correct answer is D. Using symbols to assist the client in locating rooms is beneficial for a client with Alzheimer's as they may have difficulty remembering locations. Symbols can serve as visual cues to help them navigate and reduce confusion. A: Seating the client at a dining table with multiple residents may be overwhelming and lead to agitation. B: Providing several meal choices can be confusing and increase indecision for someone with Alzheimer's. C: Giving complete directions all at once may be too much information for the client to process. Instead, simple and clear instructions are more effective.
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A nurse in a psychiatric unit is caring for a client who has obsessive-compulsive disorder. Which of the following actions should the nurse take?
- A. Allow the client to perform compulsive rituals
- B. Discourage discussion about the compulsions
- C. Encourage the client to use thought-stopping techniques
- D. Limit the client’s decision-making opportunities
Correct Answer: C
Rationale: The correct answer is C: Encourage the client to use thought-stopping techniques. This is because thought-stopping techniques are a common cognitive-behavioral intervention used to help individuals with obsessive-compulsive disorder interrupt and replace their distressing thoughts or compulsive behaviors with healthier alternatives. By encouraging the client to use these techniques, the nurse can help the client develop coping strategies to manage their symptoms effectively.
Choices A, B, and D are incorrect because they do not address the core issue of obsessive-compulsive disorder and may even exacerbate the client's symptoms. Allowing the client to perform compulsive rituals reinforces maladaptive behaviors, discouraging discussion about the compulsions limits the client's ability to seek support and understanding, and limiting decision-making opportunities may increase the client's anxiety and feelings of lack of control.
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 caring for a client who has posttraumatic stress disorder related to military service. Which of the following actions should the nurse take?
- A. Encourage the client to suppress feelings of trauma
- B. Assign the same staff to care for the client each day
- C. Address the client in an authoritative manner
- D. Limit the amount of time spent with the client
Correct Answer: B
Rationale: The correct answer is B: Assign the same staff to care for the client each day. Consistency in care providers helps establish trust and a sense of safety for clients with PTSD. This familiarity can reduce anxiety and improve therapeutic rapport. Encouraging the client to suppress feelings of trauma (A) can be harmful as it may worsen symptoms. Addressing the client in an authoritative manner (C) can trigger feelings of threat. Limiting time spent with the client (D) can hinder the development of a therapeutic relationship.
A nurse is caring for a school-aged child who has conduct disorder and is being physically aggressive toward other children in the unit. Which of the following actions should the nurse take first?
- A. Place the child in seclusion
- B. Use therapeutic hold technique
- C. Apply wrist restraints
- D. Administer risperidone
Correct Answer: A
Rationale: The correct answer is A: Place the child in seclusion. The first step in managing physically aggressive behavior in a child with conduct disorder is to ensure the safety of the child and others. Placing the child in seclusion helps prevent harm to others while allowing the child to calm down in a controlled environment. Using therapeutic hold technique (B) or applying wrist restraints (C) may escalate the situation and increase the risk of harm. Administering risperidone (D) is a medication intervention that should be considered only after addressing the immediate safety concerns.
A nurse is speaking with a client. Which of the following responses by the nurse demonstrates the communication technique of reflection?
- A. I would like to sit with you for a while
- B. You feel upset when this happens?
- C. Let’s work together to try to solve your problem
- D. Can you tell me what is happening now?
Correct Answer: B
Rationale: The correct answer is B because it demonstrates the communication technique of reflection. By saying "You feel upset when this happens?", the nurse is reflecting the client's feelings back to them, showing empathy and understanding. This technique helps the client feel heard and validated. Choice A is empathetic but does not reflect the client's feelings. Choice C focuses on problem-solving. Choice D is open-ended but does not reflect the client's emotions.