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A nurse is making a home visit for a 16-year-old adolescent who attempted suicide. Which of the following behaviors should alert the nurse that the adolescent still has suicidal intent?
- A. Telling his parents that he doesn't want to talk about the suicide attempt.
- B. Stating that he wants to be with his peers more than with his parents.
- C. Preferring to eat his meals while watching TV.
- D. Planning to give his CD collection to his girlfriend.
Correct Answer: D
Rationale: The correct answer is D: Planning to give his CD collection to his girlfriend. This behavior indicates the adolescent is making future plans involving giving away possessions, which could be a sign of continued suicidal ideation. Giving away prized possessions is often seen as a way of saying goodbye or preparing for death. Choices A, B, and C do not necessarily indicate ongoing suicidal intent. A may suggest avoidance, B may indicate a desire for peer support, and C may be a personal preference. Therefore, D is the most concerning behavior that warrants immediate attention.
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A nurse is caring for a client who has been diagnosed with obsessive-compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?
- A. Limit the amount of time available to interact with others
- B. Focus attention on meaningful tasks
- C. Manipulate and control others’ behaviors
- D. Decrease anxiety to a tolerable level
Correct Answer: D
Rationale: The correct answer is D: Decrease anxiety to a tolerable level. In OCD, repetitive behaviors like picking up after others serve to reduce anxiety stemming from obsessive thoughts. This behavior acts as a coping mechanism to alleviate distress. Choice A is incorrect as the behavior is driven by anxiety, not a desire to limit interaction time. Choice B is incorrect as the behavior is not necessarily meaningful but rather a compulsive act. Choice C is incorrect as the behavior is self-directed, not aimed at controlling others.
A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? (Select all that apply.)
- A. Urinary retention and constipation
- B. Tongue thrusting and lip smacking
- C. Fine hand tremors and pill rolling
- D. Facial grimacing and eye blinking
- E. Involuntary pelvic rocking and hip thrusting movements
Correct Answer: B, D, E
Rationale: Tardive dyskinesia involves involuntary repetitive movements such as lip smacking, facial grimacing, and pelvic rocking.
A nurse in an acute mental health facility is caring for a client who jumps out of her chair and begins to shout angrily at the clients around her. Which of the following actions should the nurse take first?
- A. Call for assistance to place the client in restraints.
- B. Escort the client to an unlocked seclusion room.
- C. Offer the client a PRN antianxiety medication.
- D. Speak to the client calmly, giving simple directions.
Correct Answer: D
Rationale: The correct answer is D: Speak to the client calmly, giving simple directions. This is the first action the nurse should take because it focuses on de-escalating the situation and ensuring the safety of the client and others. By speaking calmly and giving simple directions, the nurse can help the client regain control and potentially prevent further escalation. Calling for assistance to place the client in restraints (A) should only be used as a last resort for safety reasons. Escorting the client to an unlocked seclusion room (B) may escalate the situation further. Offering a PRN antianxiety medication (C) should only be considered after assessing the client and obtaining an order from a healthcare provider.
A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?
- A. Delusions
- B. Hallucinations
- C. Social withdrawal
- D. Agitation
- E. Flat affect
Correct Answer: C
Rationale: The correct answer is C: Social withdrawal. Negative symptoms in schizophrenia involve the absence or reduction of normal behaviors or functions. Social withdrawal is a common negative symptom, characterized by the client's lack of interest in social interactions. Delusions (A) and hallucinations (B) are positive symptoms, involving the presence of abnormal behaviors or perceptions. Agitation (D) is a symptom of increased motor activity, not a negative symptom. Flat affect (E) refers to a lack of emotional expression, which is also a negative symptom. In summary, social withdrawal aligns with the definition of negative symptoms in schizophrenia, making it the correct answer.
A nurse is providing teaching for a client who has binge-eating disorder and is morbidly obese. The client has been prescribed orlistat. Which of the following statements indicates to the nurse that the client understands the teaching?
- A. "I will take my dose of orlistat every morning an hour before breakfast."
- B. "I will stop taking orlistat and call my doctor if my urine gets darker in color."
- C. "I will eat a no-fat diet to prevent side effects from the medication."
- D. "I will feel less hungry during meals while I am taking orlistat."
Correct Answer: B
Rationale: The correct answer is B: "I will stop taking orlistat and call my doctor if my urine gets darker in color." This statement indicates understanding because dark urine can be a sign of liver injury, a serious side effect of orlistat. The client recognizing this symptom and knowing to contact the doctor promptly demonstrates comprehension of the medication's potential risks.
A: "I will take my dose of orlistat every morning an hour before breakfast." - This statement does not indicate understanding of the medication's specific instructions.
C: "I will eat a no-fat diet to prevent side effects from the medication." - While a low-fat diet is recommended with orlistat, this statement does not address potential serious side effects.
D: "I will feel less hungry during meals while I am taking orlistat." - This statement does not address the medication's side effects or potential risks.