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A nurse is contributing to the plan of care for a client who has acute delirium. Which of the following interventions should the nurse include in the plan of care?
- A. Limit the client's need to make decisions.
- B. Discourage visitation from the client's family.
- C. Keep the client's room dark at night.
- D. Provide a high-stimulation environment for the client.
Correct Answer: A
Rationale: Limiting the client's need to make decisions helps reduce stress and confusion, which can exacerbate symptoms of delirium. Simplifying choices and providing a structured environment can aid in orientation and reduce cognitive overload.
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A nurse is collecting data from a client who has schizophrenia. Which of the following client statements indicates that the client is experiencing a command hallucination?
- A. Can you see these spiders crawling all over me?
- B. The aliens are going to abduct me tonight.
- C. Are you planning to kill me?
- D. The voices told me to quit eating the food here.
Correct Answer: D
Rationale: The statement 'The voices told me to quit eating the food here' is indicative of a command hallucination, where the client hears voices instructing them to take specific actions. This distinguishes it from visual hallucinations or delusions.
A nurse is speaking with the sibling of a client who refuses to see visitors. Which of the following actions should the nurse take?
- A. Arrange for the sibling to visit the client in the dayroom.
- B. Refer the sibling to the client's provider.
- C. Tell the sibling the client does not want visitors.
- D. Encourage the client to visit with the sibling.
Correct Answer: C
Rationale: Informing the sibling that the client does not want visitors respects the client’s wishes and maintains their autonomy and confidentiality. This action upholds the client’s rights without pressuring them.
A nurse is collecting data for a health history from a client who has antisocial personality disorder. Which of the following clinical findings is associated with this disorder?
- A. Withdrawn behaviors.
- B. Blunted affect.
- C. Excessively anxious.
- D. Exploitive of others.
Correct Answer: D
Rationale: Exploitive of others is a key characteristic of antisocial personality disorder. Individuals often disregard others’ rights and manipulate them for personal gain, aligning with the disorder’s profile.
A nurse is caring for a client who has dementia and is experiencing an increased number of falls. Which of the following actions should the nurse take?
- A. Request a consult with recreational therapy.
- B. Lower the window shade in the client's room.
- C. Place the client in a room close to the nurses' station.
- D. Obtain a PRN prescription for a vest restraint.
Correct Answer: C
Rationale: Placing the client near the nurses' station allows for closer monitoring and quicker intervention, which can help prevent falls. This is a practical, non-restrictive measure to enhance safety.
A client is becoming increasingly agitated
- A. anxious
- B. and tense. The nurse notes a clenched jaw and a change in the pitch of the client's voice. Which of the following interventions should the nurse implement first?
- C. Verbally de-escalate the client.
- D. Take the client to the seclusion room.
- E. Place the client in restraints.
- F. Obtain a prescription for haloperidol.
Correct Answer: A
Rationale: Verbally de-escalating the client is the first step to reduce agitation and prevent escalation. This non-invasive approach prioritizes safety and communication.