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A nurse is caring for multiple clients on a mental health unit. Which of the following clients should the nurse attend to first?
- A. A client who is repeatedly approaching the nurses' station to request medication for his anxiety.
- B. A client who is standing in her room, yelling obscenities, and throwing her clothes.
- C. A client who has bipolar disorder and is continuously pacing at the end of the hall.
- D. A client in the dayroom who is screaming at other clients about what is on the television.
Correct Answer: B
Rationale: A client yelling obscenities and throwing clothes poses a more direct risk due to potential escalation to physical harm. This behavior requires immediate attention over anxiety, pacing, or verbal disruptions.
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A nurse is caring for a client who has depression and reports only sleeping a few hours each night. Which of the following instructions should the nurse give the client to promote sleep?
- A. You should drink a glass of wine 1 hour before you go to bed.
- B. You should eat a meal just prior to bedtime.
- C. You should take a nap after lunch.
- D. You should limit yourself to two caffeinated beverages per day.
Correct Answer: D
Rationale: Limiting caffeine intake to two beverages per day can promote better sleep. Caffeine is a stimulant that can interfere with falling asleep and staying asleep, especially if consumed later in the day. This instruction supports improved sleep quality.
A nurse is caring for a client who has an opioid use disorder. The nurse should anticipate that the provider will prescribe which of the following medications for treatment?
- A. Phenobarbital.
- B. Diazepam.
- C. Chlordiazepoxide.
- D. Buprenorphine.
Correct Answer: D
Rationale: Buprenorphine is a partial opioid agonist used in medication-assisted treatment for opioid use disorder, helping to reduce cravings and withdrawal symptoms. It’s specifically indicated for this condition.
A nurse is caring for a client who has an anxiety disorder. The client transforms their anxiety into physical manifestations. The nurse should recognize that the client is exhibiting which of the following manifestations?
- A. Reaction formation.
- B. Somatization.
- C. Sublimation.
- D. Intellectualization.
Correct Answer: B
Rationale: Somatization involves the transformation of anxiety into physical symptoms, such as pain or fatigue, without a medical cause. This is a way the body expresses psychological distress through physical symptoms, aligning with the client’s behavior.
A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior. Which of the following actions should the nurse take?
- A. Document the client's behavior in the medical record every 1 hr.
- B. Keep staff interactions with the client to a minimum.
- C. Request the provider renew the prescription in 24 hr.
- D. Provide range-of-motion exercises to all extremities every 2 hr.
Correct Answer: D
Rationale: Providing range-of-motion exercises every 2 hours helps to prevent complications associated with immobility, such as muscle atrophy and pressure ulcers. This is a critical safety measure for clients in restraints.
A nurse is collecting data from a client who has antisocial personality disorder. Which of the following findings should the nurse expect?
- A. Preoccupation with details.
- B. Manipulative behaviors.
- C. Impulsiveness.
- D. Splitting.
Correct Answer: B
Rationale: Manipulative behaviors are a common finding in individuals with antisocial personality disorder. These individuals often use manipulation to gain control or achieve their own goals without regard for others, aligning with the disorder’s characteristics.