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A nurse is planning care for a client who has bipolar disorder and is experiencing a depressive episode. Which of the following interventions should the nurse include?
- A. Encourage excessive physical activity
- B. Provide frequent rest periods
- C. Discourage interaction with others
- D. Implement a rigid daily routine
Correct Answer: B
Rationale: The correct answer is B: Provide frequent rest periods. During a depressive episode in bipolar disorder, the client may experience fatigue and lack of motivation. Providing frequent rest periods allows for adequate relaxation and helps to conserve energy. This intervention supports the client in managing their symptoms and promotes self-care.
A: Encouraging excessive physical activity may exacerbate fatigue and worsen symptoms during a depressive episode.
C: Discouraging interaction with others may increase feelings of isolation and worsen depressive symptoms.
D: Implementing a rigid daily routine may add pressure and stress to the client, which can be counterproductive during a depressive episode.
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A nurse is planning care for a client who has a history of alcohol use disorder and is experiencing withdrawal. Which of the following interventions should the nurse include in the plan?
- A. Administer disulfiram
- B. Monitor for seizures
- C. Restrict fluid intake
- D. Provide a high-protein diet
Correct Answer: B
Rationale: The correct answer is B: Monitor for seizures. During alcohol withdrawal, clients are at risk for seizures due to central nervous system hyperexcitability. Monitoring for seizures allows for prompt intervention if they occur. Administering disulfiram (A) is used to deter alcohol consumption, not for withdrawal. Restricting fluid intake (C) can worsen dehydration, while providing a high-protein diet (D) is not a priority during alcohol withdrawal.
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.
A nurse is planning care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following interventions should the nurse include?
- A. Encourage the client to listen to loud music
- B. Ask the client directly about the content of the hallucinations
- C. Instruct the client to ignore the voices
- D. Avoid discussing the hallucinations with the client
Correct Answer: B
Rationale: The correct answer is B: Ask the client directly about the content of the hallucinations. This intervention is important as it helps the nurse understand the nature and content of the hallucinations, allowing for better assessment and tailored intervention. By directly asking the client, the nurse can gather valuable information to provide appropriate care and support. Encouraging the client to listen to loud music (A) may exacerbate the hallucinations. Instructing the client to ignore the voices (C) may not be effective and could lead to increased distress. Avoiding discussing the hallucinations with the client (D) hinders the therapeutic communication and understanding of the client's experience.
A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?
- A. Weigh the client twice per day
- B. Prepare the client for electroconvulsive therapy
- C. Set a weight gain goal of 2.2kg (5lbs) per week
- D. Encourage the client to participate in family therapy
Correct Answer: C
Rationale: The correct answer is C: Set a weight gain goal of 2.2kg (5lbs) per week. This intervention is appropriate for a client with anorexia nervosa to promote healthy weight restoration. Rapid weight gain can be harmful, so setting a realistic goal helps prevent complications. Weighing the client twice per day (A) can exacerbate anxiety and reinforce obsessive behaviors. Electroconvulsive therapy (B) is not indicated for anorexia nervosa. Encouraging family therapy (D) may be beneficial, but the priority is weight restoration.
A nurse is assessing a client who has histrionic personality disorder. Which of the following findings should the nurse expect?
- A. Lack of remorse
- B. Attention seeking
- C. Splitting of staff
- D. Identity disturbance
Correct Answer: B
Rationale: The correct answer is B: Attention seeking. In histrionic personality disorder, individuals often seek attention by being overly dramatic, seductive, or provocative. This behavior is a key characteristic of the disorder. Lack of remorse (A) is more indicative of antisocial personality disorder. Splitting of staff (C) is more commonly associated with borderline personality disorder. Identity disturbance (D) is a feature of borderline personality disorder as well. In summary, attention seeking behavior is a hallmark trait of histrionic personality disorder, making choice B the correct answer in this scenario.