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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. This intervention helps the client explore and address underlying emotions driving self-mutilation, promoting self-awareness and healthier coping mechanisms. Option A may escalate feelings of lack of control, triggering more self-harm. Option C isolates the client, worsening feelings of abandonment. Option D is dismissive and oversimplifies the behavior.
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A nurse is providing discharge teaching to a client who has bipolar disorder and a new prescription for lithium. Which statement by the client indicates an understanding of the teaching?
- A. I will reduce my sodium intake to help lithium work better
- B. I should take my medication on an empty stomach
- C. I need to drink 2-3 liters of water each day
- D. I can stop taking lithium once my symptoms improve
Correct Answer: C
Rationale: The correct answer is C: "I need to drink 2-3 liters of water each day." This statement indicates an understanding of the teaching because lithium can cause dehydration and increase the risk of toxicity. Adequate hydration helps to prevent this. Choice A is incorrect because reducing sodium intake is not directly related to lithium's effectiveness. Choice B is incorrect as lithium should be taken with food to reduce gastrointestinal side effects. Choice D is incorrect because stopping lithium abruptly can lead to a relapse of symptoms.
A client with schizophrenia is prescribed risperidone. Which of the following should the nurse monitor for as an adverse effect of this medication?
- A. Increased blood pressure
- B. Weight gain
- C. Excessive salivation
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Weight gain. Risperidone is known to cause metabolic side effects, including weight gain. This is due to its impact on appetite regulation and metabolism. Monitoring weight is crucial to prevent potential health risks associated with obesity. The other options are incorrect as risperidone is not known to cause increased blood pressure (A), excessive salivation (C), or bradycardia (D). Monitoring for these effects is not typically necessary when a client is prescribed risperidone.
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: Correct Answer: B
Rationale:
1. Fluoxetine is an antidepressant that can initially increase suicidal thoughts in some individuals, especially at the beginning of treatment.
2. This phenomenon is known as "activation syndrome" and is important for clients to be aware of.
3. Monitoring for any signs of increased suicidal thoughts is crucial for client safety.
4. Options A, C, and D are incorrect because fluoxetine does not provide immediate mood improvement, does not require avoiding tyramine-rich foods, and does not affect lithium levels.
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.