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 caring for a client who has depression following a recent job loss. Which of the following questions should the nurse ask to assess the client’s personal coping skills?
- A. How does this situation affect your life?
- B. Do you see your current situation affecting your future?
- C. Can you describe how you are currently feeling?
- D. How have you dealt with similar situations in the past?
Correct Answer: D
Rationale: The correct answer is D: How have you dealt with similar situations in the past? This question assesses the client's personal coping skills by exploring their past strategies for managing challenging situations. By understanding their previous coping mechanisms, the nurse can identify effective approaches to support the client in managing their current depression.
A: How does this situation affect your life? - This question focuses on the impact of the current situation but does not directly assess the client's coping skills.
B: Do you see your current situation affecting your future? - This question explores the client's perspective on the influence of the situation on their future, but it does not specifically address coping skills.
C: Can you describe how you are currently feeling? - This question evaluates the client's emotional state but does not directly assess coping skills.
A nurse is providing teaching to a client who has obsessive-compulsive disorder and engages in excessive handwashing. Which of the following instructions should the nurse include?
- A. Encourage the client to stop washing hands
- B. Allow additional time for rituals
- C. Limit ritual behaviors immediately
- D. Ignore the compulsions
Correct Answer: B
Rationale: The correct answer is B: Allow additional time for rituals. This is because abruptly stopping the handwashing rituals can lead to increased anxiety and distress for the client. Allowing additional time for rituals can help the client feel more in control and gradually work towards reducing the behavior. Encouraging the client to stop washing hands (A) abruptly can be counterproductive. Limiting ritual behaviors immediately (C) can also increase anxiety. Ignoring the compulsions (D) may worsen the condition.
A nurse is caring for a client who has major depressive disorder and is prescribed sertraline. Which of the following instructions should the nurse provide?
- A. Take the medication at bedtime
- B. Expect results within 1 to 2 days
- C. Avoid consuming grapefruit juice
- D. Stop taking the medication once symptoms improve
Correct Answer: C
Rationale: The correct answer is C: Avoid consuming grapefruit juice. Grapefruit juice can interact with sertraline, leading to increased levels of the medication in the bloodstream, potentially causing side effects or toxicity. It is essential for the nurse to instruct the client to avoid grapefruit juice to ensure the safe and effective use of sertraline. Taking the medication at bedtime (choice A) is not specifically necessary for sertraline. Expecting results within 1 to 2 days (choice B) is incorrect as antidepressants like sertraline typically take weeks to show full effects. Stopping the medication once symptoms improve (choice D) can be dangerous as abruptly discontinuing an antidepressant can lead to withdrawal symptoms or a relapse of depression.
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 in a psychiatric unit is caring for a client who has obsessive-compulsive disorder. Which of the following actions should the nurse take?
- A. Allow the client to perform compulsive rituals
- B. Discourage discussion about the compulsions
- C. Encourage the client to use thought-stopping techniques
- D. Limit the client’s decision-making opportunities
Correct Answer: C
Rationale: The correct answer is C: Encourage the client to use thought-stopping techniques. This is because thought-stopping techniques are a common cognitive-behavioral intervention used to help individuals with obsessive-compulsive disorder interrupt and replace their distressing thoughts or compulsive behaviors with healthier alternatives. By encouraging the client to use these techniques, the nurse can help the client develop coping strategies to manage their symptoms effectively.
Choices A, B, and D are incorrect because they do not address the core issue of obsessive-compulsive disorder and may even exacerbate the client's symptoms. Allowing the client to perform compulsive rituals reinforces maladaptive behaviors, discouraging discussion about the compulsions limits the client's ability to seek support and understanding, and limiting decision-making opportunities may increase the client's anxiety and feelings of lack of control.
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