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A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include?
- A. Provide frequent rest periods
- B. Discourage social interaction
- C. Allow unlimited physical activity
- D. Limit the client's choices
Correct Answer: A
Rationale: The correct answer is A: Provide frequent rest periods. During mania, clients with bipolar disorder have high energy levels and may engage in excessive activities, leading to physical and mental exhaustion. Providing frequent rest periods helps to prevent burnout and promotes relaxation. Choice B is incorrect as social interaction can provide support and prevent feelings of isolation. Choice C is incorrect as unlimited physical activity can exacerbate manic symptoms. Choice D is incorrect as limiting choices can cause frustration and may escalate the manic episode.
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A nurse is caring for a client who has schizophrenia and takes clozapine. Which of the following findings is a priority for the nurse to report to the provider?
- A. Nausea
- B. Random blood glucose 130 mg/dL
- C. Heart rate 104 per minute
- D. Sore throat
Correct Answer: D
Rationale: The correct answer is D: Sore throat. A priority finding to report with clozapine is agranulocytosis, which presents with symptoms like sore throat. This is crucial to detect early to prevent severe infection. A: Nausea is a common side effect of clozapine but not a priority over potential agranulocytosis. B: Random blood glucose of 130 mg/dL is slightly elevated but not an immediate concern. C: Heart rate of 104 per minute may be a side effect but is not as critical as agranulocytosis. Reporting the sore throat promptly can lead to timely intervention and prevent serious complications.
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 creating a plan of care for a client who has major depressive disorder. Which of the following interventions should the nurse include in the plan?
- A. Discourage the client from expressing feelings of anger
- B. Identify and schedule alternative group activities for the client
- C. Encourage physical activity for the client during the day
- D. Keep a bright light on in the clients room at night
Correct Answer: C
Rationale: The correct answer is C: Encourage physical activity for the client during the day. Physical activity has been shown to improve mood and reduce symptoms of depression by increasing endorphins. This intervention can help the client combat feelings of sadness and hopelessness.
A: Discouraging the client from expressing feelings of anger is not therapeutic and may further suppress emotions, worsening depression.
B: Identifying and scheduling alternative group activities can be helpful, but it may not directly address the physical aspect of depression.
D: Keeping a bright light on in the client's room at night may disrupt sleep patterns and is not a targeted intervention for major depressive disorder.
A nurse is planning care for a client with acute delirium. Which of the following instructions should the nurse include in the plan?
- A. Reinforce the clients orientation with the calendar
- B. Refute the clients perception of visual hallucinations
- C. Teach the client assertive techniques
- D. Assign the client to a different caregiver each shift
Correct Answer: A
Rationale: The correct answer is A: Reinforce the client's orientation with the calendar. This is because in acute delirium, the client may experience confusion and disorientation. Using a calendar can help provide structure and aid in orientation. Choice B is incorrect as refuting hallucinations may worsen the client's agitation. Choice C is incorrect as assertive techniques are not typically used in managing acute delirium. Choice D is incorrect as consistency in caregivers is important for continuity of care in delirium management.
A school nurse is caring for an adolescent client whose teacher reports changes in school performance and withdrawal from interaction with classmates. Which of the following interventions is the nurse’s priority at this time?
- A. Contact the adolescent’s parents
- B. Suggest the adolescent join support groups
- C. Ask the adolescent if he is considering hurting himself
- D. Determine when the adolescent’s change in behavior began
Correct Answer: C
Rationale: The correct answer is C: Ask the adolescent if he is considering hurting himself. This is the priority intervention because it addresses the immediate safety and well-being of the adolescent. By directly asking about thoughts of self-harm, the nurse can assess the risk of suicide and provide appropriate interventions if necessary. Contacting the parents (choice A) can be important but not the priority in this situation. Suggesting support groups (choice B) and determining when the behavior changes began (choice D) are important steps but not as urgent as assessing for suicidal ideation.