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A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain about the client's disruptive behaviors. Which of the following initial actions should the nurse take?
- A. Talk to the nursing staff.
- B. Talk to the client and identify the specific limits that are required of the client's behavior.
- C. Discuss the problem in a community meeting with the other clients on the unit present.
- D. Escort the client to her room each time the nurse observes the client socializing with others.
Correct Answer: B
Rationale: The correct initial action for the nurse to take is choice B: Talk to the client and identify the specific limits that are required of the client's behavior. This option is the most appropriate because it directly addresses the client's behavior and sets clear expectations. By having a one-on-one conversation with the client, the nurse can establish boundaries and consequences for disruptive behavior, which may help modify the client's actions. Talking to the nursing staff (choice A) may be necessary later, but addressing the client directly is the first step. Discussing the problem in a community meeting (choice C) may embarrass the client and not address the behavior directly. Escorting the client to her room (choice D) does not address the underlying issue of lying and disruptive behavior.
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A nurse is caring for a client who has anorexia nervosa and overexercises to avoid gaining weight. Which of the following nursing actions should the nurse take?
- A. Praise the client for looking at herself in a mirror.
- B. Ask the client to agree to talk to a nurse whenever she feels the urge to exercise.
- C. Reprimand the client about the potential damage that has occurred due to overexercising.
- D. Restrict the client from being weighed.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Asking the client to agree to talk to a nurse whenever she feels the urge to exercise is the most appropriate action. This approach promotes open communication and allows for timely intervention to address the client's excessive exercise behavior. It also demonstrates empathy and support, which are crucial in managing anorexia nervosa. By creating a safe space for the client to express her feelings, the nurse can help prevent further harm caused by overexercising.
Summary of other choices:
A: Praising the client for looking at herself in a mirror may reinforce distorted body image perceptions and unhealthy behaviors.
C: Reprimanding the client could lead to feelings of guilt and shame, exacerbating the client's condition.
D: Restricting the client from being weighed may not address the underlying issue of overexercising and can contribute to feelings of lack of control.
A nurse is speaking with a client experiencing anxiety. Which of the following responses is most therapeutic?
- A. "Most clients with anxiety benefit from lying down."
- B. "Come with me to an area where we can talk without interruption."
- C. "Providers usually recommend relaxation exercises for clients who are upset."
- D. "An antianxiety pill works best for situations like this."
Correct Answer: B
Rationale: The correct answer is B. Bringing the client to an area for uninterrupted conversation shows active listening and support. It promotes a safe space for the client to express feelings and reduces anxiety. Choice A is incorrect as it assumes all clients benefit from lying down, which may not be true. Choice C is incorrect because recommending relaxation exercises may not address the client's immediate needs. Choice D is incorrect as medication should not be the first response for managing anxiety without exploring other options first.
A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates understanding of a relapse prevention plan?
- A. "I can remember when my hallucinations first began."
- B. "I know which of my hallucinations trigger a relapse."
- C. "I record the number of hallucinations I have each day."
- D. "I will read as much information as I can about schizophrenia."
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Option B, "I know which of my hallucinations trigger a relapse," indicates the client's understanding of identifying triggers for relapse. This awareness is crucial in preventing relapse by avoiding or managing triggers effectively. Understanding personal triggers helps the client take proactive steps to maintain stability.
Incorrect Choices:
A: "I can remember when my hallucinations first began." This statement does not demonstrate a proactive plan for relapse prevention.
C: "I record the number of hallucinations I have each day." Monitoring hallucinations is important but does not necessarily indicate understanding of relapse prevention.
D: "I will read as much information as I can about schizophrenia." While education is vital, it does not directly address relapse prevention strategies.
A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client?
- A. Watching a video with a group in the day room
- B. Walking with the nurse in the courtyard
- C. Participating in a basketball game in the gym
- D. Joining a group discussion about a local election
Correct Answer: B
Rationale: The correct answer is B: Walking with the nurse in the courtyard. During the manic phase, individuals with bipolar disorder may have high energy levels and increased impulsivity. Walking in the courtyard with the nurse provides a safe outlet for physical activity and helps to channel excess energy in a constructive manner. This activity also allows for one-on-one interaction, which can help the client focus and reduce boredom. Other options like watching a video with a group or participating in a basketball game may be too stimulating and could exacerbate manic symptoms. Joining a group discussion about a local election might be overwhelming and less effective in managing the client's energy level and attention.
A client becomes very dejected and states, "No one really cares what happens to me. Life isn't worth living anymore." Which of the following responses should the nurse make?
- A. "Of course people care. Your family comes to visit every day."
- B. "Tell me who you think doesn't care about you."
- C. "Why do you feel that way?"
- D. "I care about you, and I am concerned that you feel so sad."
Correct Answer: D
Rationale: The correct answer is D because it shows empathy and acknowledges the client's feelings while also expressing concern. It validates the client's emotions and offers support without dismissing or invalidating their experience. Choice A is incorrect as it focuses on the family's visits, which may not address the client's underlying emotional distress. Choice B puts the client on the spot and may come off as confrontational. Choice C is open-ended but lacks the immediate reassurance and support the client needs.