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A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?
- A. "It sounds like you’re having a difficult time."
- B. "Have you talked to your parents about this yet?"
- C. "Why do you think you are so anxious?"
- D. "How long has this been going on?"
Correct Answer: A
Rationale: The correct answer is A: "It sounds like you’re having a difficult time." This response shows empathy and validation towards the client's feelings, which can help build rapport and trust. It acknowledges the client's emotions without making assumptions or judgments. It opens up the conversation for the client to further express their concerns and feelings.
Option B is incorrect because it assumes the client has not talked to their parents yet, which may not be the case and can invalidate the client's feelings. Option C is incorrect as it puts the client on the spot and may come off as confrontational. Option D is incorrect as it focuses on the duration rather than addressing the client's current emotional state.
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A nurse is caring for a newly admitted client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first?
- A. Discuss alternative coping strategies with the client.
- B. Identify precipitating factors for ritualistic behaviors.
- C. Instruct the client on relaxation techniques for use when anxiety increases.
- D. Provide a structured activity schedule for the client.
Correct Answer: B
Rationale: The correct answer is B: Identify precipitating factors for ritualistic behaviors. This is the first action the nurse should take because understanding the triggers for the client's ritualistic behaviors is essential in developing an effective care plan. By identifying these factors, the nurse can work with the client to address them and potentially reduce the frequency or intensity of the OCD symptoms. Discussing coping strategies (choice A), teaching relaxation techniques (choice C), and providing a structured activity schedule (choice D) are important interventions but should come after identifying the triggers to ensure they are tailored to the individual's specific needs.
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 caring for an adolescent female who has an eating disorder. The client is 162.6 cm (64 in) tall and weighs 38.56 kg (85 lb). Upon assessment, which of the following manifestations should the nurse expect? (Select all that apply.)
- A. Amenorrhea
- B. Verbalized desire to gain weight
- C. Altered body image
- D. Hyperactivity
- E. Bradycardia
Correct Answer: A, C, D, E
Rationale: Anorexia nervosa is often associated with amenorrhea, distorted body image, excessive activity, and bradycardia due to malnutrition.
A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity?
- A. The client runs 4 miles outdoors every afternoon.
- B. The client drinks 2 liters of liquids daily.
- C. The client eats 2-3 grams of sodium-containing foods daily.
- D. The client eats foods high in tyramine.
Correct Answer: A
Rationale: The correct answer is A. Running 4 miles daily causes excessive sweating, leading to dehydration and potential lithium toxicity. Lithium is excreted through the kidneys and dehydration can decrease kidney function, causing lithium levels to rise. Choices B and C are actually helpful as adequate hydration and normal sodium intake reduce the risk of lithium toxicity. Choice D is irrelevant as tyramine is not linked to lithium toxicity.
A nurse is caring for a client who has bipolar disorder and a new prescription for valproate. Which of the following instructions should the nurse give the client about the use of this medication?
- A. Thyroid function tests should be performed every 6 months.
- B. A pretreatment electroencephalogram (EEG) will be done.
- C. Liver function tests should be monitored.
- D. High serum sodium levels can cause toxic levels of valproate.
Correct Answer: C
Rationale: Valproate is metabolized in the liver, requiring regular liver function monitoring.