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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 assessing a client who is experiencing alcohol withdrawal. Which of the following findings should the nurse expect?
- A. Bradycardia
- B. Visual hallucinations
- C. Hypotension
- D. Hyperactivity
Correct Answer: B
Rationale: The correct answer is B: Visual hallucinations. During alcohol withdrawal, the client may experience hallucinations due to the central nervous system's hyperexcitability. This symptom is typically seen within 12-24 hours of the last drink. Bradycardia (A) and hypotension (C) are less common in alcohol withdrawal; tachycardia and hypertension are more typical. Hyperactivity (D) is not a common symptom and is more likely to be seen in stimulant withdrawal.
A nurse is assessing a newly admitted client who has schizophrenia and takes thioridazine. Which of the following findings should the nurse document as an adverse effect of this medication?
- A. Anhedonia
- B. Waxy flexibility
- C. Contractions of the jaw
- D. Incongruent affect
Correct Answer: C
Rationale: The correct answer is C: Contractions of the jaw. Thioridazine is an antipsychotic medication known to cause extrapyramidal side effects such as dystonia, which can manifest as contractions of the jaw. Anhedonia (A) is the inability to experience pleasure, not a side effect of thioridazine. Waxy flexibility (B) is a symptom of catatonia, not a side effect of thioridazine. Incongruent affect (D) refers to a mismatch between expression and emotion, not a side effect of thioridazine.
A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer’s disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include?
- A. Position the mattress on the floor
- B. Install sensor devices on outside doors
- C. Encourage physical activity prior to bedtime
- D. Put locks at top of doors
Correct Answer: A
Rationale: The correct answer is A: Position the mattress on the floor. Placing the mattress on the floor reduces the risk of injury if the client falls out of bed while wandering at night. This option prioritizes safety by minimizing the distance of potential falls. Installing sensor devices on outside doors (B) may alert the caregiver but does not directly address the risk of falls. Encouraging physical activity prior to bedtime (C) could increase agitation and wandering behavior. Putting locks at the top of doors (D) could pose a safety risk if emergency access is needed.
A nurse is assessing a client who has histrionic personality disorder. Which of the following findings should the nurse expect?
- A. Lack of remorse
- B. Attention seeking
- C. Splitting of staff
- D. Identity disturbance
Correct Answer: B
Rationale: The correct answer is B: Attention seeking. In histrionic personality disorder, individuals often seek attention by being overly dramatic, seductive, or provocative. This behavior is a key characteristic of the disorder. Lack of remorse (A) is more indicative of antisocial personality disorder. Splitting of staff (C) is more commonly associated with borderline personality disorder. Identity disturbance (D) is a feature of borderline personality disorder as well. In summary, attention seeking behavior is a hallmark trait of histrionic personality disorder, making choice B the correct answer in this scenario.
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.