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A nurse is developing a behavioral contract with a client who has antisocial personality disorder. Which of the following client goals should the nurse include in the contract?
- A. Use projection during group therapy
- B. Increase self-esteem
- C. Use bargaining skills for behavioral consequences
- D. Decrease the number of verbal outbursts
Correct Answer: D
Rationale: The correct answer is D: Decrease the number of verbal outbursts. For a client with antisocial personality disorder, managing impulsivity and aggression is crucial. Decreasing verbal outbursts helps improve social interactions and relationships. Using projection (A) can exacerbate manipulative behavior. Increasing self-esteem (B) may not address the core issues of the disorder. Using bargaining skills (C) might reinforce manipulative tendencies rather than promoting genuine change in behavior.
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A nurse is caring for a client who is involuntarily admitted for major depressive disorder and refuses to take prescribed antianxiety medication. Which of the following actions should the nurse take?
- A. Inform the client that he does not have the right to refuse medication
- B. Administer the medication to the client via IM injection
- C. Offer the client the medication at the next scheduled dose time
- D. Implement consequences until the client takes the medication
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Implementing consequences until the client takes the medication is the most appropriate action as the client is involuntarily admitted. This approach ensures the client's safety and well-being by addressing the refusal to take prescribed medication. Administering medication via IM injection (B) may escalate the situation and violate the client's rights. Informing the client that he does not have the right to refuse medication (A) is inaccurate and may lead to resistance. Offering the medication at the next scheduled dose time (C) does not address the client's refusal.
A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include?
- A. Encourage group activities
- B. Provide frequent rest periods
- C. Offer high-calorie snacks
- D. Allow unlimited physical activity
Correct Answer: B
Rationale: The correct answer is B: Provide frequent rest periods. During manic episodes in bipolar disorder, individuals have high energy levels, reduced need for sleep, and increased activity levels. Providing frequent rest periods helps prevent exhaustion and promotes relaxation, which can help stabilize mood. Encouraging group activities (A) may exacerbate manic symptoms due to increased stimulation. Offering high-calorie snacks (C) can lead to poor dietary choices and worsen physical health. Allowing unlimited physical activity (D) can be dangerous as individuals in a manic state may engage in risky behaviors.
A nurse in a psychiatric unit is providing discharge instructions to a client who has schizophrenia and a new prescription for clozapine. Which of the following statements should the nurse include?
- A. Get up quickly from a sitting or lying position
- B. Expect to have an increased risk of infection
- C. Avoid exposure to sunlight
- D. Limit fluid intake
Correct Answer: B
Rationale: The correct answer is B: Expect to have an increased risk of infection. Clozapine is known to suppress the immune system, increasing the risk of infections. The nurse should educate the client to monitor for signs of infection, practice good hygiene, and promptly report any symptoms of infection to their healthcare provider.
Choice A is incorrect because getting up quickly can lead to orthostatic hypotension, a common side effect of clozapine. Choice C is incorrect as clozapine does not specifically require avoiding sunlight. Choice D is incorrect as limiting fluid intake is not a requirement for clozapine.
A nurse in a provider’s office is assessing a school-age child who has a spiral fracture. The parent of the child provides different accounts for the cause of the injury. Which of the following actions should the nurse take first?
- A. Request that the parent leaves the room while you interview the child
- B. Report suspected abuse to child protective services
- C. Ask the child how the injury occurred
- D. Determine the immediate safety needs of the child
Correct Answer: B
Rationale: Correct Answer: B. Report suspected abuse to child protective services.
Rationale: Reporting suspected abuse to child protective services is the first step to ensure the safety and well-being of the child. In cases of conflicting stories from the parent and the child, it is crucial to prioritize the child's safety. Child protective services can investigate further to determine the true cause of the injury and provide necessary support and protection for the child.
Summary of other choices:
A: Requesting the parent to leave the room may be necessary for further assessment, but ensuring the child's safety is the priority.
C: Asking the child how the injury occurred is important but should come after ensuring the child's immediate safety.
D: Determining the immediate safety needs of the child is crucial, but reporting suspected abuse takes precedence to address potential harm.
A nurse is planning care for a client who has experienced intimate partner abuse. The nurse should identify which of the following outcomes as the priority?
- A. The client joins a support group
- B. The client identifies techniques to reduce stress
- C. The client develops a safety plan
- D. The client identifies support systems
Correct Answer: C
Rationale: The correct answer is C: The client develops a safety plan. This is the priority outcome because it addresses the immediate safety of the client who is experiencing intimate partner abuse. A safety plan helps the client to identify strategies to protect themselves and seek help in times of danger. Joining a support group (A), identifying stress reduction techniques (B), and identifying support systems (D) are important steps in the client's overall recovery process but addressing safety concerns is crucial to prevent further harm. It is important to prioritize safety before addressing other aspects of the client's well-being.