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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.
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A nurse on an inpatient mental health unit is caring for a client who has major depressive disorder and malnutrition. Which of the following actions should the nurse take to improve the client's nutritional status?
- A. Enroll the client in a nutritional class on the unit.
- B. Weigh the client at the same time every morning.
- C. Ask the provider to arrange a consultation with the facility chaplain.
- D. Sit with the client during meals and snacks.
Correct Answer: D
Rationale: The correct answer is D: Sit with the client during meals and snacks. This option promotes a therapeutic relationship, encourages the client to eat, and provides emotional support. By sitting with the client, the nurse can monitor food intake, address any eating difficulties, and offer encouragement. This approach helps the client feel supported and valued, which can positively impact their nutritional intake.
Choice A is incorrect as a nutritional class may not address the client's immediate needs. Choice B is incorrect as weighing the client daily does not directly improve their nutritional status. Choice C is incorrect as involving the chaplain may not address the nutritional needs of the client.
A nurse is providing teaching to a client who has alcohol use disorder about Alcoholics Anonymous (AA). Which of the following client statements indicates an understanding of the program's basic concepts?
- A. "I am responsible for my alcoholism."
- B. "I need to identify things that cause me to be an alcoholic."
- C. "I am powerless against my addiction to alcohol."
- D. "I need to see a counselor who will be responsible for my recovery."
Correct Answer: C
Rationale: AA is based on the principle of acknowledging powerlessness over addiction and seeking support.
A nurse is caring for a client who reports bilateral knee pain after hiking this past weekend in the mountains on rough ground. He says he is concerned because his cousin died from bone cancer recently. Which of the following actions should the nurse take?
- A. Tell the client that it is unlikely that he has bone cancer.
- B. Ask the client why he thinks the pain isn't a result of hiking.
- C. Suggest genetic testing so the client can understand his risks.
- D. Explain that the provider will see him and determine a course of action.
Correct Answer: D
Rationale: The nurse should provide reassurance while ensuring proper medical evaluation.
A nurse is assisting a client who has schizophrenia prepare a relapse plan. Which of the following statements should the nurse make?
- A. "You should be aware that excessive sleeping is an early sign of relapse."
- B. "Relapse is an indication that you are not taking your medications properly."
- C. "You should keep your provider's and therapist's number with you."
- D. "Taking an additional dose of medication is appropriate as soon as signs of relapse appear."
Correct Answer: C
Rationale: The correct answer is C because keeping the provider's and therapist's number with the client is crucial for quick access to support during a potential relapse. This step promotes timely intervention and communication with the healthcare team, which can help prevent escalation of symptoms. Option A is incorrect because excessive sleeping may not be a universal early sign of relapse for all individuals with schizophrenia. Option B is incorrect because relapse can occur despite proper medication adherence. Option D is incorrect because self-medicating without healthcare provider guidance can be dangerous and may worsen symptoms.
A nurse in the emergency department is caring for a client who reports chest pain, headache, and shortness of breath. He continues to state, “I don't know why my wife left me.” The client receives a diagnosis of anxiety. The nurse realizes the client’s findings support which level of anxiety?
- A. Mild
- B. Moderate
- C. Severe
- D. Panic
Correct Answer: D
Rationale: The correct answer is D: Panic. The client is experiencing severe physical symptoms (chest pain, headache, shortness of breath) and is unable to identify the source of his distress, which indicates a high level of anxiety. Panic level is characterized by overwhelming fear and physical symptoms that can mimic a heart attack. Mild anxiety (A) is characterized by minor discomfort, moderate anxiety (B) involves increased heart rate and muscle tension, and severe anxiety (C) includes more pronounced physical symptoms. In this case, the client's presentation aligns most closely with panic level anxiety.