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A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity?
- A. The client runs 4 miles outdoors every afternoon.
- B. The client drinks 2 liters of liquids daily.
- C. The client eats 2-3 grams of sodium-containing foods daily.
- D. The client eats foods high in tyramine.
Correct Answer: A
Rationale: The correct answer is A. Running 4 miles daily causes excessive sweating, leading to dehydration and potential lithium toxicity. Lithium is excreted through the kidneys and dehydration can decrease kidney function, causing lithium levels to rise. Choices B and C are actually helpful as adequate hydration and normal sodium intake reduce the risk of lithium toxicity. Choice D is irrelevant as tyramine is not linked to lithium toxicity.
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A nurse is caring for a client who is depressed and refuses to participate in group therapy or perform activities of daily living. Which of the following statements should the nurse make to the client?
- A. "I will assist you in getting out of bed and getting dressed."
- B. "You can remain in bed until you feel well enough to join the group."
- C. "The unit rules state that you may not remain in bed."
- D. "If you don’t participate in your care, you will not get better."
Correct Answer: A
Rationale: Rationale: Choice A is correct because it demonstrates empathy, support, and encouragement. By offering assistance in getting out of bed and getting dressed, the nurse is promoting the client's self-care and well-being. This statement acknowledges the client's feelings while also providing the necessary support to engage in daily activities.
Incorrect Choices:
B: This choice enables the client's avoidance behavior and does not promote active participation in therapy or self-care.
C: This statement is authoritarian and does not address the client's emotional state or needs, which can worsen the client's depression.
D: This statement is negative and may induce guilt or shame in the client, which is counterproductive in supporting their mental health recovery.
A nurse is conducting a group therapy session for several clients. The group is laughing at a joke one of the clients told, when a client who is schizophrenic jumps up and runs out of the room yelling, "You are all making fun of me!" The nurse should identify this behavior as which of the following characteristics of schizophrenia?
- A. Magical thinking
- B. Delusions of grandeur
- C. Ideas of reference
- D. Looseness of association
Correct Answer: C
Rationale: The correct answer is C: Ideas of reference. This behavior is indicative of ideas of reference, a common symptom of schizophrenia where individuals believe that neutral events or comments are directed at them personally. In this case, the client's perception of laughter at a joke led them to believe it was directed towards them, triggering a paranoid reaction. This is different from magical thinking (A) which involves belief in unrealistic events, delusions of grandeur (B) which involves exaggerated beliefs in one's importance, and looseness of association (D) which is characterized by disconnected thoughts. The other choices are not relevant to the scenario provided.
A nurse in a long-term care facility is caring for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
- A. Post a written schedule of daily activities
- B. Use an overhead loudspeaker to announce events
- C. Provide a consistent daily routine
- D. Allow the client to choose free-time activities
Correct Answer: C
Rationale: The correct answer is C: Provide a consistent daily routine. Individuals with Alzheimer's disease benefit from a structured routine as it helps reduce confusion and anxiety. Consistency in daily activities can enhance familiarity and comfort for the client, promoting a sense of security and predictability. This routine can also aid in maintaining the client's cognitive function and overall well-being.
Incorrect choices:
A: Post a written schedule of daily activities - While this may be helpful, a consistent routine is more effective in providing stability for individuals with Alzheimer's.
B: Use an overhead loudspeaker to announce events - Loud noises and sudden announcements can be overwhelming for individuals with Alzheimer's, causing distress.
D: Allow the client to choose free-time activities - While promoting autonomy is important, too many choices can lead to confusion and difficulty in decision-making for individuals with Alzheimer's.
A nurse is discussing the manifestations of alcohol withdrawal with a client who has a history of alcohol use disorder. Which of the following client statements indicates understanding?
- A. "I should expect tremors to start less than 24 hours after I stop drinking."
- B. "Disulfiram will block my cravings for alcohol."
- C. "My symptoms should last about 5 to 7 days once they begin."
- D. "It is important that I take vitamin C to prevent cirrhosis or other liver damage."
Correct Answer: A
Rationale: The correct answer is A because alcohol withdrawal symptoms, including tremors, typically begin within 6-24 hours after the last drink. This statement shows an accurate understanding of the timing of alcohol withdrawal manifestations. Choice B is incorrect because Disulfiram is a medication used to deter alcohol consumption, not block cravings. Choice C is incorrect because alcohol withdrawal symptoms can last beyond 5-7 days. Choice D is incorrect because vitamin C does not prevent cirrhosis or liver damage from alcohol abuse.
A nurse in a mental health clinic is assessing a client who was brought in by her adult daughter stating that her mother has not been able to leave her home for weeks because she is afraid to be outdoors alone. The nurse should anticipate planning care for managing which of the following phobias?
- A. Xenophobia
- B. Acrophobia
- C. Mysophobia
- D. Agoraphobia
Correct Answer: D
Rationale: Agoraphobia is the fear of being in open or public spaces, leading to avoidance behavior.