Nokea
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.
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A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the following actions should the nurse take?
- A. Set limits for the relationship
- B. Promote the use of transference by the client
- C. Instruct the client on how he should behave
- D. Engage in friendly interactions with the client
Correct Answer: A
Rationale: The correct answer is A: Set limits for the relationship. In a therapeutic relationship, setting boundaries and limits is crucial to establish a safe and professional environment. This helps the client understand the expectations and maintain appropriate behavior. By setting limits, the nurse can ensure a therapeutic focus and prevent any potential harm or misunderstandings.
Choice B (Promote the use of transference by the client) is incorrect because encouraging transference can lead to unrealistic expectations and hinder the therapeutic process. Choice C (Instruct the client on how he should behave) is incorrect as it undermines the client's autonomy and may create a power dynamic. Choice D (Engage in friendly interactions with the client) is incorrect as it blurs professional boundaries and may lead to a lack of objectivity.
A nurse is caring for an adolescent client who has conduct disorder. The client reports that she has received five speeding tickets in the past 6 months. Which of the following interventions should the nurse take?
- A. Make a contract with the client not to drive over the speed limit.
- B. Call the local police and alert them to the client's car license plate number and the make and model of her car.
- C. Ask the client to "hand over the keys" to you and tell her that now she must use a cab or other public transportation until your next session.
- D. Inform the client that she cannot drink and drive.
Correct Answer: A
Rationale: The correct answer is A: Make a contract with the client not to drive over the speed limit. This intervention is appropriate as it establishes clear boundaries and expectations for the client's behavior, addressing the issue of multiple speeding tickets. By creating a contract, the nurse can work with the client to set specific goals and consequences for adhering to the speed limit. This method promotes accountability and helps the client understand the importance of safe driving practices.
Other choices are incorrect:
B: Calling the local police would breach confidentiality and trust, which is not ethical.
C: Taking away the client's keys may be seen as punitive and could lead to resistance or defiance.
D: While important, the issue of drinking and driving is not directly related to the client's speeding tickets.
A client who has coronary artery disease tells the nurse he is afraid of dying from a heart attack. Which of the following responses should the nurse make?
- A. "Perhaps you should discuss this with your physician."
- B. "Of course you aren't going to die, at least not in the immediate future."
- C. "I recommend you exercise daily and avoid smoking to decrease your risk."
- D. "Tell me more about these fears of dying from a heart attack."
Correct Answer: D
Rationale: Encouraging the client to talk about their fears fosters therapeutic communication.
Where should a nurse assign a client experiencing manic behavior?
- A. Semi-private room across from the day room
- B. Private room in a quiet location
- C. Semi-private room across from the snack area
- D. Shared room near the nursing station
Correct Answer: B
Rationale: The correct answer is B: Private room in a quiet location. This choice is appropriate because a client experiencing manic behavior requires a calm and quiet environment to minimize stimulation and help reduce agitation. Placing the client in a private room can provide the necessary space for the client to calm down and prevent potential triggers for further manic episodes.
Other choices are incorrect:
A: A semi-private room across from the day room may expose the client to increased noise and activity, which can exacerbate manic behavior.
C: A semi-private room across from the snack area may lead to distractions and potential interactions that can escalate the manic behavior.
D: A shared room near the nursing station may not offer the privacy and quiet environment needed for a client experiencing manic behavior to stabilize.
A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?
- A. Affective flattening.
- B. Bizarre behavior.
- C. Illogicality.
- D. Somatic delusions.
Correct Answer: A
Rationale: The correct answer is A: Affective flattening. Negative symptoms in schizophrenia refer to deficits in normal emotional responses or behaviors. Affective flattening specifically involves a reduction in the expression of emotions, such as reduced facial expressions and tone of voice. This is a core negative symptom in schizophrenia. Bizarre behavior (choice B) is associated with positive symptoms, such as hallucinations and delusions. Illogicality (choice C) is a cognitive symptom related to disorganized thinking. Somatic delusions (choice D) are also positive symptoms involving false beliefs about the body. By process of elimination, Affective flattening is the correct answer.