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A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan?
- A. Encourage the client to lie down in a quiet room.
- B. Refer to the hallucinations as if they are real.
- C. Ask the client directly what he is hearing.
- D. Avoid eye contact with the client.
Correct Answer: C
Rationale: The correct answer is C: Ask the client directly what he is hearing. This action is crucial in assessing the content and severity of the hallucinations, which helps in tailoring appropriate interventions. By directly inquiring about the auditory hallucinations, the nurse demonstrates active listening and shows empathy towards the client's experiences. This approach also fosters a trusting therapeutic relationship.
Choice A: Encouraging the client to lie down in a quiet room does not address the auditory hallucinations directly and may not be effective in managing them.
Choice B: Referring to the hallucinations as if they are real can validate and reinforce the client's delusions, worsening the symptoms.
Choice D: Avoiding eye contact with the client may convey a message of discomfort or disinterest, hindering the establishment of rapport and trust.
In summary, choice C is the most appropriate as it directly addresses the client's symptoms and facilitates a comprehensive assessment, which is essential for developing an effective care plan.
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A nurse is caring for a client who has a history of opioid use disorder. Which medication should the nurse anticipate administering to prevent withdrawal symptoms?
- A. Methadone
- B. Disulfiram
- C. Naloxone
- D. Bupropion
Correct Answer: A
Rationale: Rationale: A nurse should anticipate administering Methadone to prevent withdrawal symptoms in a client with opioid use disorder. Methadone is a long-acting opioid agonist that helps manage withdrawal symptoms and cravings, making it an effective treatment option. Disulfiram is used for alcohol dependence, Naloxone is an opioid antagonist used for overdose reversal, and Bupropion is an antidepressant. These medications are not indicated for preventing opioid withdrawal symptoms.
A nurse is admitting a client who has dementia to a long-term care facility. The client tells the nurse that she lived in this facility years ago and took care of all the residents by herself. The nurse should document this as which of the following findings?
- A. Projection
- B. Perseveration
- C. Agnosia
- D. Confabulation
Correct Answer: D
Rationale: The correct answer is D: Confabulation. Confabulation is the creation of false memories or distortion of actual memories without the intention to deceive. In this scenario, the client is not intentionally lying, but rather recalling a memory that did not occur. This is common in individuals with dementia. Projection (A) involves attributing one's thoughts or feelings to someone else. Perseveration (B) is the persistent repetition of a response. Agnosia (C) is the inability to recognize familiar objects or people. In this case, the client's statement aligns most closely with confabulation, making it the correct choice.
A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan?
- A. Encourage the client to lie down in a quiet room.
- B. Refer to the hallucinations as if they are real.
- C. Ask the client directly what he is hearing.
- D. Avoid eye contact with the client.
Correct Answer: C
Rationale: The correct answer is C: Ask the client directly what he is hearing. This is the best action because it acknowledges the client's experience without reinforcing the hallucinations as real. By directly asking the client about their hallucinations, the nurse can gather important information to better understand the client's experience and tailor the care plan accordingly.
Choice A is incorrect because lying down in a quiet room may not address the client's auditory hallucinations. Choice B is incorrect as it can validate the hallucinations as real, which can exacerbate the client's symptoms. Choice D is incorrect as avoiding eye contact can create a barrier to communication.
A nurse is caring for a client with major depressive disorder who has a new prescription for fluoxetine. Which statement by the client indicates an understanding of the medication?
- A. I should expect to see improvement in my mood within a few days.
- B. I may experience increased thoughts of suicide at the beginning of treatment.
- C. I need to avoid foods high in tyramine while taking this medication.
- D. I will need to have my lithium levels checked regularly.
Correct Answer: B
Rationale: The correct answer is B. This statement indicates an understanding of the medication because it acknowledges the possibility of increased thoughts of suicide at the beginning of treatment, which is a crucial side effect to monitor for in clients starting on antidepressants like fluoxetine. It shows that the client is aware of the potential risks associated with the medication and is prepared to address them with healthcare providers if they occur.
Choice A is incorrect because improvement in mood with fluoxetine typically takes several weeks, not a few days. Choice C is incorrect as tyramine-related dietary restrictions are associated with MAOIs, not SSRIs like fluoxetine. Choice D is incorrect as lithium levels are not monitored with fluoxetine therapy.
A nurse is providing teaching to a client who has generalized anxiety disorder about strategies to manage anxiety. Which of the following should the nurse include? (Select all that apply)
- A. Progressive muscle relaxation
- B. Journaling
- C. Avoiding stressful situations
- D. Deep breathing exercises
- E. Drinking caffeinated beverages
Correct Answer: A,B,D
Rationale: The correct strategies for managing anxiety include A: Progressive muscle relaxation, B: Journaling, and D: Deep breathing exercises. Progressive muscle relaxation helps reduce muscle tension and promote relaxation. Journaling allows the client to express emotions and thoughts, reducing stress. Deep breathing exercises help calm the nervous system and reduce anxiety symptoms.
Avoiding stressful situations (C) is not a feasible long-term solution as it may limit the client's ability to cope with anxiety triggers. Drinking caffeinated beverages (E) can actually worsen anxiety symptoms due to the stimulant effect.