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A nurse is contributing to the plan of care for a client who has schizophrenia. The client often directs brief
- A. hostile verbal outbursts toward the staff. Which of the following interventions should the nurse recommend?
- B. Encourage the client to participate in a board game.
- C. Touch the client on the shoulder to console them.
- D. Bring a security guard whenever approaching the client.
- E. Use a calm, clear tone when speaking to the client.
Correct Answer: D
Rationale: Using a calm, clear tone when speaking to the client is an effective intervention for managing hostile verbal outbursts. Calm communication helps de-escalate the situation and prevents further agitation. It shows the client that the nurse is in control and can provide a stable, reassuring presence, which is essential for building trust and maintaining a therapeutic environment.
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A nurse is receiving report on four clients at the beginning of the shift. Which of the following clients should the nurse check first?
- A. A client who is hearing command hallucinations.
- B. A client who is verbalizing ideas of reference.
- C. A client who is using neologisms.
- D. A client who is demonstrating clang associations.
Correct Answer: A
Rationale: A client who is hearing command hallucinations should be prioritized first because command hallucinations can be particularly dangerous. These hallucinations can involve voices instructing the client to harm themselves or others. Immediate assessment and intervention are crucial to ensure the client's safety and to prevent potential harm.
A nurse is monitoring a client who is receiving haloperidol. Which of the following findings is the priority to report to the provider?
- A. Hypoactive bowel sounds in all four quadrants.
- B. Client report of dry mouth.
- C. Constant opening and closing of mouth.
- D. Client report of photosensitivity.
Correct Answer: C
Rationale: Constant opening and closing of the mouth, also known as tardive dyskinesia, is a serious side effect of haloperidol and other antipsychotic medications. This condition involves involuntary muscle movements and can be irreversible. It is crucial to report this finding to the provider immediately for assessment and potential adjustment of the medication regimen.
A nurse is caring for a client who has chronic alcohol use disorder. Which of the following laboratory findings should the nurse monitor to evaluate the client's nutritional status?
- A. Serum creatinine.
- B. Thiamine level.
- C. Urinalysis.
- D. Erythrocyte sedimentation rate.
Correct Answer: B
Rationale: Thiamine (vitamin B1) deficiency is a well-known complication of chronic alcohol use disorder. Alcohol interferes with the absorption and utilization of thiamine, leading to deficiencies that can cause severe neurological problems, such as Wernicke's encephalopathy and Korsakoff's syndrome. Monitoring thiamine levels is crucial in assessing and managing the nutritional status of clients with chronic alcohol use disorder.
A nurse in a mental health facility is contributing to the plan of care for a new client. Which of the following actions should the nurse plan to include in the working phase of the nurse-client relationship?
- A. Determine whether the client's goals are met.
- B. Collect data about the client's current health status.
- C. Provide the client with information on problem-solving.
- D. Establish a regular meeting time with the client.
Correct Answer: C
Rationale: Providing the client with information on problem-solving is an essential component of the working phase of the nurse-client relationship. During this phase, the nurse and client work collaboratively to address issues, develop coping strategies, and implement interventions aimed at improving the client's mental health.
A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states
- A. That looks like a snake, and I won't let it take all of my blood. Which of the following responses should the nurse make?
- B. Your provider requires this blood specimen.
- C. You must be mistaken. Snakes cannot be in the clinic.
- D. I'm using a syringe to obtain your blood, not a snake.
- E. I don't see a snake, but that must be scary for you.
Correct Answer: D
Rationale: Acknowledging the client's hallucination and expressing empathy is the most appropriate response. By saying, 'I don't see a snake, but that must be scary for you,' the nurse acknowledges the client's fear and provides comfort without reinforcing the hallucination. This approach helps build trust and rapport, making it easier to proceed with the necessary procedure while ensuring the client's emotional wellbeing.