Nokea
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.
You may also like to solve these questions
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 home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
- A. Replace the carpet with hardwood floors.
- B. Encourage physical activity prior to bedtime.
- C. Wear clothing with zippers instead of buttons.
- D. Place locks at the tops of exterior doors.
Correct Answer: D
Rationale: The correct answer is D: Place locks at the tops of exterior doors. This is important for the safety of a client with Alzheimer's disease who may wander and get lost. Placing locks at the tops of exterior doors can help prevent the client from leaving the house unsupervised, reducing the risk of harm. Other choices are incorrect because: A: Replacing carpet with hardwood floors may not directly address safety concerns. B: Encouraging physical activity prior to bedtime may disrupt sleep patterns. C: Wearing clothing with zippers instead of buttons is a personal preference and not directly related to safety.
A nurse is speaking with the caregiver of a client who has Alzheimer's disease. The caregiver states, "Providing constant care is very stressful and is affecting all areas of my life." Which of the following actions should the nurse take?
- A. Suggest that the caregiver seek a prescription for an antipsychotic medication for the client.
- B. Recommend allowing the client to have time alone in their room throughout the day.
- C. Discuss methods of how to communicate with the client about resolving problem behaviors.
- D. Assist the caregiver to arrange for a daycare program for the client.
Correct Answer: D
Rationale: The correct answer is D: Assist the caregiver to arrange for a daycare program for the client. This option addresses the caregiver's need for respite and support, allowing them to take a break from constant care. It promotes the client's social engagement and activities in a safe environment, offering the caregiver time to attend to their own needs. This option recognizes the importance of caregiver well-being in managing the stress associated with caring for a client with Alzheimer's disease.
Incorrect options:
A: Suggesting antipsychotic medication for the client is not appropriate without further assessment and should not be the first intervention.
B: Allowing the client time alone does not address the caregiver's need for support and respite.
C: Discussing communication methods is important, but it doesn't directly address the caregiver's need for relief from constant care.
E, F, G: Not provided in the question.
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: The correct answer is B: "I may experience increased thoughts of suicide at the beginning of treatment." This statement indicates an understanding of the medication because fluoxetine, an SSRI, can initially increase suicidal ideation in clients with major depressive disorder due to sudden improvement in energy levels before mood improvement. This is important for the client to know for safety monitoring.
Choice A is incorrect as improvement in mood may take several weeks, not days. Choice C is incorrect as avoiding tyramine-rich foods is relevant for MAOIs, not SSRIs like fluoxetine. Choice D is incorrect as lithium levels are monitored for clients taking lithium, not fluoxetine.
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 in the plan?
- A. Place the client in seclusion when he exhibits signs of anxiety.
- B. Encourage the client to spend time in the dayroom.
- C. Withdraw the client's TV privileges if he does not attend group therapy.
- D. Encourage the client to take frequent rest periods.
Correct Answer: D
Rationale: The correct answer is D: Encourage the client to take frequent rest periods. During mania, clients with bipolar disorder may experience heightened energy levels and decreased need for sleep. Encouraging rest periods can help regulate energy levels and promote better sleep patterns, which are crucial in managing manic episodes. Placing the client in seclusion when anxious (choice A) can increase feelings of isolation and worsen symptoms. Encouraging the client to spend time in the dayroom (choice B) may not address the need for rest. Withdrawing TV privileges (choice C) may not directly address the client's manic symptoms.