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A nurse is developing a plan of care for a client who has post-traumatic stress disorder. Which of the following interventions should the nurse include?
- A. Encourage the client to suppress traumatic memories
- B. Discourage the client from discussing the trauma
- C. Encourage the client to use relaxation techniques
- D. Limit the client’s participation in activities
Correct Answer: C
Rationale: The correct answer is C: Encourage the client to use relaxation techniques. This is important in managing symptoms of PTSD by helping the client to reduce anxiety and stress levels. Relaxation techniques, such as deep breathing and mindfulness, can help the client cope with distressing thoughts and emotions. Encouraging the client to use these techniques promotes self-soothing and emotional regulation.
Choice A is incorrect because suppressing traumatic memories can worsen symptoms and lead to increased distress. Choice B is incorrect as discussing the trauma in a safe and supportive environment is a key component of PTSD therapy. Choice D is incorrect as limiting activities can hinder the client's recovery process.
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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.
A nurse is leading a grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression?
- A. I don’t know how I could cope if I didn’t have my family’s support
- B. It’ll be a long time before I’m happy again
- C. I don’t feel anything but numbness anymore
- D. I feel like I’m angry at the whole world right now
Correct Answer: C
Rationale: The correct answer is C: "I don’t feel anything but numbness anymore." This statement indicates a significant emotional numbness, which is a common symptom of clinical depression. It suggests a lack of normal emotional responses, which can be concerning.
Choice A does not specifically indicate clinical depression but rather expresses a need for support. Choice B reflects a natural response to grief and does not necessarily indicate depression. Choice D suggests anger, which can also be a normal part of the grieving process.
In summary, Choice C is the correct answer as it directly points to a key symptom of clinical depression, while the other choices reflect common emotional responses to grief that may not necessarily indicate depression.
A nurse is assessing a client who has been taking clozapine for 3 months. Which of the following findings should the nurse report to the provider immediately?
- A. Constipation
- B. Sore throat
- C. Dry mouth
- D. Drowsiness
Correct Answer: B
Rationale: The correct answer is B: Sore throat. Clozapine can cause agranulocytosis, a serious condition characterized by a low white blood cell count, which can manifest as sore throat, fever, or flu-like symptoms. Immediate reporting is crucial to monitor for potential complications. Constipation (A), dry mouth (C), and drowsiness (D) are common side effects of clozapine but do not require immediate reporting unless severe.
A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. Which of the following medications should the nurse administer?
- A. Methadone
- B. Chlordiazepoxide
- C. Naltrexone
- D. Disulfiram
Correct Answer: B
Rationale: The correct answer is B: Chlordiazepoxide. This medication is a benzodiazepine used to manage alcohol withdrawal symptoms by reducing anxiety, agitation, and preventing seizures. Benzodiazepines help to stabilize the central nervous system during alcohol withdrawal, making it the appropriate choice for this client.
Incorrect Choices:
A: Methadone is used for opioid withdrawal, not alcohol withdrawal.
C: Naltrexone is used for alcohol dependence treatment by reducing cravings, not for acute withdrawal symptoms.
D: Disulfiram is used as a deterrent for alcohol consumption, not for managing withdrawal symptoms.
A nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect?
- A. Increased energy
- B. Restlessness
- C. Depersonalization
- D. Euphoric mood
Correct Answer: B
Rationale: The correct answer is B: Restlessness. In generalized anxiety disorder, clients often experience restlessness due to excessive worry and fear. This can manifest as fidgeting, inability to relax, and feeling on edge. Restlessness is a common symptom seen in individuals with this disorder. Increased energy (choice A) is less likely as anxiety tends to deplete energy. Depersonalization (choice C) is more commonly associated with dissociative disorders, not generalized anxiety disorder. Euphoric mood (choice D) is not typically seen in clients with generalized anxiety disorder, as they are more likely to feel tense and worried.