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A nurse is caring for a client with schizophrenia who is experiencing auditory hallucinations. Which intervention should the nurse implement first?
- A. Ask the client what the voices are saying
- B. Tell the client the voices are not real
- C. Encourage the client to listen to music
- D. Teach the client deep breathing exercises
Correct Answer: A
Rationale: The correct answer is A: Ask the client what the voices are saying. This intervention should be implemented first because it helps the nurse assess the content of the hallucinations and understand the client's experience. By asking about the voices, the nurse can gather important information to develop an appropriate care plan. Choice B is incorrect as it denies the client's experience and may lead to mistrust. Choice C may provide temporary distraction but does not address the hallucinations directly. Choice D may help with anxiety but does not specifically address the auditory hallucinations. It is crucial to prioritize understanding the client's perception and providing appropriate support.
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A nurse is caring for a client who has a history of opioid use disorder. Which medication should the nurse anticipate administering to prevent withdrawal symptoms?
- A. Methadone
- B. Disulfiram
- C. Naloxone
- D. Bupropion
Correct Answer: A
Rationale: Rationale: A nurse should anticipate administering Methadone to prevent withdrawal symptoms in a client with opioid use disorder. Methadone is a long-acting opioid agonist that helps manage withdrawal symptoms and cravings, making it an effective treatment option. Disulfiram is used for alcohol dependence, Naloxone is an opioid antagonist used for overdose reversal, and Bupropion is an antidepressant. These medications are not indicated for preventing opioid withdrawal symptoms.
A nurse is admitting a client who has dementia to a long-term care facility. The client tells the nurse that she lived in this facility years ago and took care of all the residents by herself. The nurse should document this as which of the following findings?
- A. Projection
- B. Perseveration
- C. Agnosia
- D. Confabulation
Correct Answer: D
Rationale: The correct answer is D: Confabulation. Confabulation is the creation of false memories or distortion of actual memories without the intention to deceive. In this scenario, the client is not intentionally lying, but rather recalling a memory that did not occur. This is common in individuals with dementia. Projection (A) involves attributing one's thoughts or feelings to someone else. Perseveration (B) is the persistent repetition of a response. Agnosia (C) is the inability to recognize familiar objects or people. In this case, the client's statement aligns most closely with confabulation, making it the correct choice.
A nurse is caring for a client who has a history of opioid use disorder. Which medication should the nurse anticipate administering to prevent withdrawal symptoms?
- A. Methadone
- B. Disulfiram
- C. Naloxone
- D. Bupropion
Correct Answer: A
Rationale: The correct answer is A: Methadone. Methadone is a long-acting opioid agonist that helps prevent withdrawal symptoms in individuals with opioid use disorder by stabilizing opioid receptors. This allows for gradual withdrawal and reduces cravings. Disulfiram (B) is used for alcohol use disorder. Naloxone (C) is an opioid antagonist used for opioid overdose reversal. Bupropion (D) is used for smoking cessation and depression, not opioid withdrawal.
A nurse is teaching a client who has generalized anxiety disorder about buspirone. Which statement indicates the client understands the teaching?
- A. I should take this medication as needed for acute anxiety.
- B. I may experience sedation and drowsiness with this medication.
- C. I should avoid grapefruit juice while taking this medication.
- D. This medication has a risk for dependence.
Correct Answer: C
Rationale: The correct answer is C because grapefruit juice can interact with buspirone, leading to an increased risk of side effects. Taking the medication with grapefruit juice can affect its absorption and metabolism, potentially altering its effectiveness. Choice A is incorrect because buspirone is typically taken regularly, not as needed. Choice B is incorrect because buspirone is not known for causing significant sedation or drowsiness. Choice D is incorrect because buspirone is not associated with a risk for dependence.
A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist's notes. Which of the following responses should the nurse make?
- A. "Are you not happy with your treatment?"
- B. "We can provide a copy of your records, but the therapist's notes are not included."
- C. "Why are you interested in seeing your therapist's notes?"
- D. "I don't think you will benefit from reviewing your therapist's notes right now."
Correct Answer: B
Rationale: The correct answer is B because therapist's notes are considered privileged information and are not typically included in a client's medical records. Providing these notes could compromise the therapeutic relationship and confidentiality. Option A is incorrect as it assumes the client is unhappy with treatment. Option C is inappropriate as it questions the client's motivation. Option D is incorrect as it dismisses the client's request without proper justification. Options E, F, and G are not provided, but B is the most appropriate response in this scenario.