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A nurse is planning care for a client who has borderline personality disorder and engages in self-mutilation. Which intervention should the nurse include?
- A. Restrict the client's access to personal belongings.
- B. Encourage the client to express feelings of anger.
- C. Place the client in seclusion when self-injurious behavior occurs.
- D. Tell the client to stop the self-mutilation behavior.
Correct Answer: B
Rationale: The correct answer is B: Encourage the client to express feelings of anger. For clients with borderline personality disorder, self-mutilation often stems from difficulty in managing intense emotions. Encouraging the client to express feelings of anger can help them process and cope with their emotions in a healthier way, reducing the need for self-harm. Restricting access to personal belongings (A) may increase feelings of frustration and lead to more self-mutilation. Placing the client in seclusion (C) can worsen feelings of isolation and may not address the underlying emotional issues. Simply telling the client to stop self-mutilation (D) is not effective as it overlooks the complex emotional reasons behind the behavior.
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A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?
- A. "I can continue to take St. John's wort while taking this medication."
- B. "I know it will be a couple of weeks before the medication helps me feel better."
- C. "I expect this medication to raise my blood pressure."
- D. "I should take this medication on an empty stomach."
Correct Answer: B
Rationale: The correct answer is B: "I know it will be a couple of weeks before the medication helps me feel better." This statement indicates an understanding of the teaching because amitriptyline, a tricyclic antidepressant, typically takes a few weeks to reach its full therapeutic effect in treating depressive symptoms. This indicates the client understands the delayed onset of action of the medication.
Incorrect options:
A: "I can continue to take St. John's wort while taking this medication." - St. John's wort can interact with amitriptyline, leading to potentially dangerous side effects.
C: "I expect this medication to raise my blood pressure." - Amitriptyline can indeed cause orthostatic hypotension, not raise blood pressure.
D: "I should take this medication on an empty stomach." - Amitriptyline is usually taken with food to minimize gastrointestinal side effects.
A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. Which of the following medications should the nurse expect to administer?
- A. Methadone
- B. Disulfiram
- C. Lorazepam
- D. Bupropion
Correct Answer: C
Rationale: The correct answer is C: Lorazepam. Lorazepam is a benzodiazepine used to manage alcohol withdrawal symptoms by reducing anxiety, insomnia, and seizures. It helps stabilize the client during detoxification. Methadone (A) is used for opioid withdrawal, Disulfiram (B) is a deterrent for alcohol consumption, and Bupropion (D) is used for smoking cessation.
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: The correct answer is A: Methadone. Methadone is a long-acting opioid agonist that helps prevent withdrawal symptoms in individuals with opioid use disorder by stabilizing opioid receptors. This allows for gradual withdrawal and reduces cravings. Disulfiram (B) is used for alcohol use disorder. Naloxone (C) is an opioid antagonist used for opioid overdose reversal. Bupropion (D) is used for smoking cessation and depression, not opioid withdrawal.
A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state?
- A. "What are the voices telling you?"
- B. "I realize the voices are real to you, but I don't hear anything."
- C. "Have you taken your medication today?"
- D. "How long have you been hearing the voices?"
Correct Answer: A
Rationale: The correct answer is A: "What are the voices telling you?" This response demonstrates active listening, assesses the content of the hallucinations, and helps the nurse understand the client's experience. It allows for further assessment and intervention planning. Choice B dismisses the client's experience, choice C focuses on medication compliance rather than addressing the immediate concern, and choice D addresses the duration of the hallucinations but doesn't address the current situation.
A nurse in an outpatient mental health clinic is assessing an adolescent client. The nurse should expect the adolescent to be in which of the following of Erikson's stages of psychosocial development?
- A. Generativity vs self-absorption
- B. Trust vs mistrust
- C. Intimacy vs isolation
- D. Identity vs role confusion
Correct Answer: D
Rationale: The correct answer is D: Identity vs role confusion. During adolescence, individuals go through Erikson's stage of Identity vs role confusion, where they explore and develop their own sense of self and try to establish a clear identity. This stage typically occurs during the teenage years, when adolescents are trying to figure out who they are, what they believe in, and what roles they want to play in society. This is a crucial period for developing a strong sense of self and personal identity.
Choices A, B, and C are incorrect because they correspond to different stages in Erikson's theory that do not align with the developmental tasks of adolescence. Generativity vs self-absorption is a stage typically seen in middle adulthood, Trust vs mistrust is seen in infancy, and Intimacy vs isolation is seen in early adulthood. These stages do not apply to the adolescent age group and their current developmental needs.