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A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)
- A. Give the client one simple direction at a time.
- B. Refute the client's delusions using logic.
- C. Allow the client to choose among a variety of activities each day.
- D. Reinforce orientation to time, place, and person.
- E. Establish eye contact when communicating with the client.
Correct Answer: A, D, E
Rationale: Correct Answer: A, D, E
Rationale:
A: Giving the client one simple direction at a time is important as individuals with dementia may have difficulty processing complex information.
D: Reinforcing orientation to time, place, and person helps maintain the client's sense of reality and reduce confusion.
E: Establishing eye contact when communicating with the client promotes engagement and helps in maintaining their attention.
Summary:
B: Refuting the client's delusions using logic can be counterproductive as it may cause distress and worsen their symptoms.
C: Allowing the client to choose among a variety of activities may overwhelm them. It is better to provide structured activities.
F & G: Not applicable.
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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 providing teaching to a client who has generalized anxiety disorder about strategies to manage anxiety. Which of the following should the nurse include? (Select all that apply)
- A. Progressive muscle relaxation
- B. Journaling
- C. Avoiding stressful situations
- D. Deep breathing exercises
- E. Drinking caffeinated beverages
Correct Answer: A,B,D
Rationale: The correct strategies for managing anxiety include A: Progressive muscle relaxation, B: Journaling, and D: Deep breathing exercises. Progressive muscle relaxation helps reduce muscle tension and promote relaxation. Journaling allows the client to express emotions and thoughts, reducing stress. Deep breathing exercises help calm the nervous system and reduce anxiety symptoms.
Avoiding stressful situations (C) is not a feasible long-term solution as it may limit the client's ability to cope with anxiety triggers. Drinking caffeinated beverages (E) can actually worsen anxiety symptoms due to the stimulant effect.
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 a client with borderline personality disorder and self-mutilation behavior, it is essential to address underlying emotions. Encouraging the client to express feelings of anger can help them identify and process their emotions, reducing the likelihood of resorting to self-injury. Restricting access to personal belongings (A) may lead to feelings of frustration and exacerbate the behavior. Placing the client in seclusion (C) may cause feelings of abandonment and increase distress. Simply telling the client to stop self-mutilation (D) overlooks the complex emotional reasons behind the behavior.
A nurse is assessing a client who has bipolar disorder and is experiencing a depressive episode. Which of the following findings should the nurse expect?
- A. Inability to carry out a simple task
- B. Client reports auditory hallucinations
- C. Moves quickly from one idea to the next
- D. Client expresses illusions of grandeur
Correct Answer: A
Rationale: The correct answer is A: Inability to carry out a simple task. During a depressive episode in bipolar disorder, clients often experience symptoms such as psychomotor retardation, low energy, and difficulty concentrating. This can lead to an inability to carry out simple tasks due to lack of motivation and feelings of worthlessness. Clients may struggle with daily activities and find it challenging to complete even basic tasks. This is a common symptom of depression in bipolar disorder.
Choice B is incorrect as auditory hallucinations are more commonly associated with psychotic disorders or schizophrenia. Choice C is incorrect as rapid speech and jumping from one idea to the next are more indicative of a manic episode in bipolar disorder. Choice D is incorrect as expressing illusions of grandeur is a symptom of mania, not depression.
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 SSRI used to treat depression, which may initially increase suicidal thoughts in some individuals.
2. This phenomenon is known as "activation syndrome" and requires close monitoring by healthcare providers.
3. Understanding this potential side effect shows the client's grasp of the medication's effects.
4. Choices A, C, D are incorrect as improvement in mood takes weeks, no tyramine interaction, and lithium monitoring is for a different medication.