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A nurse is condu,a client diagnosed with schizophrenia jumps up and runs out while yelling You are all making fun of me. The nurse recognizes that the client is displaying which of the following behaviors?cting a group therapy meeting and shares a humorous story. When the group laughs at the story
- A. Flight of ideas
- B. Erotomania
- C. Grandeur
- D. Ideas of reference
Correct Answer: D
Rationale: The correct answer is D: Ideas of reference. This behavior is exhibited when a person believes that neutral events or actions are directed at them personally. In this scenario, the client with schizophrenia perceives others are making fun of them when that may not be the case. This demonstrates a misinterpretation of external stimuli. Flight of ideas (A) refers to rapidly shifting from one idea to another. Erotomania (B) is a delusion where someone believes another person is in love with them. Grandeur (C) involves exaggerated beliefs of one's importance or power.
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A nurse is caring for a client who is experiencing a manic episode. Other clients begin to complain about her disruptive behavior on the unit. Which of the following actions should the nurse take?
- A. Warn the client that further disruptions will result in seclusion.
- B. Ask the client to recommend consequences for her disruptive behavior.
- C. Set limits on the client's behavior and be consistent in approach.
- D. Ignore the client's behavior,realizing it is consistent with her illness.
Correct Answer: C
Rationale: The correct answer is C: Set limits on the client's behavior and be consistent in approach. This is the best course of action because it maintains a therapeutic environment while ensuring the safety and well-being of all clients. By setting limits, the nurse establishes boundaries for acceptable behavior during the manic episode, helping to prevent harm and maintain order on the unit. Consistency in approach is crucial to provide the client with structure and predictability, which can help manage the manic symptoms and reduce potential disruptions.
Choice A is not the best option as it may escalate the situation and does not address the underlying issue. Choice B is not appropriate as it puts the responsibility on the client to determine consequences, which may not be effective in managing the behavior. Choice D is incorrect as ignoring the behavior can compromise the safety of other clients and is not a therapeutic approach to managing manic episodes.
A nurse in a mental health facility is caring for a client who is upset about the loss of privileges due to repetitive negative behavior. Which of the following statements by the nurse demonstrates the effective use of assertive communication?
- A. Why did you make the choice to behave negatively?
- B. I understand that you are angry. However, I followed the appropriate protocol.
- C. You need to calm down and forgive me before discussing this matter any further.
- D. You were made aware of the consequences of negative behavior, so you better go to your room.
Correct Answer: B
Rationale: The correct answer is B because it acknowledges the client's emotions while also asserting boundaries and explaining the nurse's actions. By stating, "I understand that you are angry. However, I followed the appropriate protocol," the nurse shows empathy towards the client's feelings and also maintains professionalism by emphasizing adherence to established procedures. This response validates the client's emotions and provides clarity on the nurse's decision-making process, promoting open communication and understanding.
Choices A, C, and D are incorrect because they lack empathy, fail to acknowledge the client's emotions, or use directive language that may escalate the situation. Choice A focuses on blaming the client, Choice C dismisses the client's feelings, and Choice D is authoritative and may trigger defensiveness.
A nurse is caring for a client who reports increased anxiety and nervousness,heat intolerance,and unintentional weight loss. Blood testing reveals decreased thyroid-stimulating hormone (TSH),elevated thyroxine (T4) and elevated triiodothyronine (T3) levels. Which of the following vital sign abnormalities does the nurse anticipate?
- A. Hypotension
- B. Tachycardia
- C. Slow respiratory rate
- D. Decreased body temperature
Correct Answer: B
Rationale: The correct answer is B: Tachycardia. In this scenario, the client is showing symptoms of hyperthyroidism, such as increased anxiety, nervousness, heat intolerance, and unintentional weight loss. The decreased TSH and elevated T4/T3 levels indicate an overactive thyroid gland.
Tachycardia is a common symptom of hyperthyroidism due to the increased metabolic rate caused by excess thyroid hormones. The body's response to the increased metabolism is to speed up the heart rate to meet the increased demand for oxygen and nutrients. Therefore, the nurse can anticipate tachycardia in this client.
The other options are incorrect because hypotension is not typically associated with hyperthyroidism; slow respiratory rate is not a common vital sign abnormality seen in hyperthyroidism; decreased body temperature is unlikely as hyperthyroidism usually causes heat intolerance and increased body temperature.
A home health nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?
- A. The partner has hired a house cleaner.
- B. The partner has placed locks at the top of the doors leading to the outside.
- C. The partner has lost 25 lb in the past 3 months.
- D. The partner redirects the client when the client is frustrated.
Correct Answer: C
Rationale: The correct answer is C because the partner losing 25 lb in the past 3 months indicates caregiver role strain. Weight loss can be a sign of stress and neglecting one's own needs while caring for someone with Alzheimer's. This choice reflects the physical toll caregiving can take.
A: Hiring a house cleaner (choice A) shows that the partner is seeking help and support, which is a positive coping strategy and does not necessarily indicate caregiver role strain.
B: Placing locks at the top of the doors (choice B) demonstrates safety measures for the client and does not directly indicate caregiver role strain.
D: Redirecting the client when frustrated (choice D) shows appropriate management of challenging behaviors and does not directly indicate caregiver role strain.
In summary, choice C is the best indicator of caregiver role strain as it reflects the physical impact of the caregiving responsibilities on the partner's well-being.
A nurse is teaching a newly licensed nurse about heparin-induced thrombocytopenia. Which of the following risk factors for this disorder should the nurse include in the teaching?
- A. Systemic lupus erythematosus
- B. Placental abruption
- C. Heparin therapy for deep-vein thrombosis
- D. Warfarin therapy for atrial fibrillation
Correct Answer: C
Rationale: Rationale: Heparin-induced thrombocytopenia (HIT) is a rare but serious complication of heparin therapy, causing a drop in platelet count. The correct answer is C because heparin therapy for deep-vein thrombosis is a known risk factor for HIT. Systemic lupus erythematosus (choice A) is associated with other complications but not specifically HIT. Placental abruption (choice B) is a condition related to pregnancy complications. Warfarin therapy for atrial fibrillation (choice D) is not a risk factor for HIT. Therefore, the nurse should focus on heparin therapy as a significant risk factor in HIT education.