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A nurse is planning care for a client who has experienced intimate partner abuse. The nurse should identify which of the following outcomes as the priority?
- A. The client joins a support group
- B. The client identifies techniques to reduce stress
- C. The client develops a safety plan
- D. The client identifies support systems
Correct Answer: C
Rationale: The correct answer is C: The client develops a safety plan. This is the priority outcome because it addresses the immediate safety of the client who is experiencing intimate partner abuse. A safety plan helps the client to identify strategies to protect themselves and seek help in times of danger. Joining a support group (A), identifying stress reduction techniques (B), and identifying support systems (D) are important steps in the client's overall recovery process but addressing safety concerns is crucial to prevent further harm. It is important to prioritize safety before addressing other aspects of the client's well-being.
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A nurse is caring for a client who has post-traumatic stress disorder (PTSD). Which of the following interventions should the nurse include in the plan of care?
- A. Encourage the client to discuss past trauma
- B. Provide a structured routine
- C. Discourage emotional expression
- D. Limit social interactions
Correct Answer: B
Rationale: The correct answer is B: Provide a structured routine. Individuals with PTSD often benefit from a predictable routine as it provides a sense of safety and control. This intervention helps regulate emotions and reduces anxiety by creating a stable environment. Encouraging the client to discuss past trauma (A) may worsen symptoms if the client is not ready. Discouraging emotional expression (C) can be harmful as it may lead to emotional suppression. Limiting social interactions (D) may increase feelings of isolation and exacerbate symptoms. It's important to prioritize stability and structure in the plan of care for clients with PTSD.
A nurse is providing discharge teaching to the parents of a child who has ADHD and a prescription for methylphenidate. Which of the following instructions should the nurse include?
- A. Administer the medication at bedtime
- B. Monitor the child’s weight frequently
- C. Give the medication with milk
- D. Discontinue the medication if insomnia occurs
Correct Answer: B
Rationale: The correct answer is B: Monitor the child’s weight frequently. This is important because methylphenidate, a stimulant used to treat ADHD, can potentially lead to appetite suppression and weight loss in children. Regular monitoring of the child's weight can help identify any significant changes and allow for appropriate interventions if needed.
Choice A is incorrect because administering the medication at bedtime can lead to insomnia due to its stimulant effects. Choice C is incorrect as there is no specific recommendation to give the medication with milk. Choice D is incorrect because insomnia is a common side effect of methylphenidate and does not necessarily warrant discontinuation of the medication unless severe or persistent.
A nurse is assessing a client who has alcohol use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Visual hallucinations
- C. Hyperactivity
- D. Increased appetite
Correct Answer: B
Rationale: The correct answer is B: Visual hallucinations. During alcohol withdrawal, the client may experience hallucinations, particularly visual ones, due to the impact of alcohol on the brain. This is known as alcohol hallucinosis. Hypotension (choice A) is not typically associated with alcohol withdrawal; in fact, hypertension is more common. Hyperactivity (choice C) is not a common symptom of alcohol withdrawal, as clients tend to be more agitated or restless. Increased appetite (choice D) is also not a typical finding during alcohol withdrawal, as many clients experience decreased appetite. Visual hallucinations are a key symptom to monitor for during alcohol withdrawal due to their potential to be distressing and require immediate intervention.
A nurse is reviewing laboratory values for a client who has bipolar disorder and a prescription for lithium. Which of the following laboratory results places the client at risk for lithium toxicity?
- A. Calcium 9.0 mg/dL
- B. Sodium 130 mEq/L
- C. Chloride 98 mEq/L
- D. Potassium 5.0 mEq/L
Correct Answer: B
Rationale: The correct answer is B: Sodium 130 mEq/L. Low sodium levels increase the risk of lithium toxicity as lithium competes with sodium for reabsorption in the kidneys. This can lead to higher lithium levels in the bloodstream, putting the client at risk for toxicity. The other choices (A, C, D) are within normal ranges and do not directly impact lithium toxicity. Therefore, the client with low sodium levels is at the highest risk for lithium toxicity.
A nurse is providing teaching to the daughter of an older client who has obsessive-compulsive disorder. Which of the following statements by the daughter indicates an understanding of the disorder?
- A. I will limit my mother’s clothing choices when she is getting dressed
- B. I will provide my mother with detailed instructions about how to perform self-care
- C. I will wake my mother up a couple of times in the night to check on her
- D. I will discourage my mother from talking about physical complaints
Correct Answer: B
Rationale: The correct answer is B: "I will provide my mother with detailed instructions about how to perform self-care." This statement indicates an understanding of obsessive-compulsive disorder (OCD) because individuals with OCD often struggle with performing daily tasks due to their obsessive thoughts and compulsive behaviors. By providing detailed instructions, the daughter is acknowledging the need for structured routines to help her mother manage her symptoms.
A: Limiting clothing choices does not address the underlying issues of OCD and may exacerbate anxiety.
C: Waking the mother up to check on her reinforces compulsions, which is counterproductive in treating OCD.
D: Discouraging the mother from talking about physical complaints does not address the core symptoms of OCD.
By choosing option B, the daughter shows insight into the importance of providing support and guidance in managing the challenges associated with OCD.