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A nurse is contributing to the plan of care for a client who has bipolar disorder and whose admission was voluntary. For which of the following interventions should the nurse confirm that the client has given informed consent?
- A. Receiving light therapy.
- B. Taking an experimental medication.
- C. Participating in a group exercise program.
- D. Attending a cognitive behavioral therapy class.
Correct Answer: B
Rationale: Experimental medications require informed consent due to the potential unknown effects and risks. Ensuring the client is fully informed about the experimental nature and possible side effects is crucial, unlike routine interventions like light therapy or therapy classes.
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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 collecting data from a client who experienced physical abuse as a child. Which of the following findings should the nurse identify as a risk factor for the client to become a perpetrator of child abuse?
- A. Low tolerance for frustration.
- B. Absence of impulsive behaviors.
- C. Involved in community activities.
- D. Submissive personality.
Correct Answer: A
Rationale: Low tolerance for frustration is a risk factor for becoming a perpetrator of child abuse as it can lead to impulsive and aggressive behaviors, increasing the likelihood of abusive actions.
A nurse is caring for a client who becomes extremely agitated and asks if they can go to a separate room to be alone for an hour. The nurse should document which of the following de-escalation techniques in the client's medical record?
- A. Therapeutic hold.
- B. Restraint.
- C. Diversion.
- D. Timeout.
Correct Answer: D
Rationale: Timeout allows the client to have a moment away from stimuli to regain control and calm down, which is a recognized de-escalation technique. This matches the client’s request and supports de-escalation efforts.
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.
A nurse in a substance use disorder clinic is explaining the alcohol recovery process to a client's family. Which of the following should the nurse identify as the first step toward successful recovery from alcohol use disorder?
- A. Form a close support network.
- B. Acknowledge an inability to control drinking.
- C. Incorporate a form of spirituality into daily life.
- D. Agree to a prescription for an alcohol use deterrent.
Correct Answer: B
Rationale: Acknowledging an inability to control drinking is crucial as it represents acceptance of the problem. Without this self-awareness, the individual is unlikely to seek or benefit from treatment options. This step is foundational, preceding the use of support networks, spirituality, or medication.