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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.
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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 clients with opioid use disorder by reducing cravings and preventing withdrawal symptoms without causing euphoria. Disulfiram (B) is used for alcohol use disorder, Naloxone (C) is an opioid antagonist used for opioid overdose reversal, and Bupropion (D) is an antidepressant that is not indicated for opioid withdrawal. By choosing Methadone, the nurse is providing appropriate pharmacological support for the client's opioid use disorder.
A client with schizophrenia is prescribed risperidone. Which of the following should the nurse monitor for as an adverse effect of this medication?
- A. Increased blood pressure
- B. Weight gain
- C. Excessive salivation
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Weight gain. Risperidone is known to cause metabolic side effects, including weight gain. This is due to its impact on appetite regulation and metabolism. Monitoring weight is crucial to prevent potential health risks associated with obesity. The other options are incorrect as risperidone is not known to cause increased blood pressure (A), excessive salivation (C), or bradycardia (D). Monitoring for these effects is not typically necessary when a client is prescribed risperidone.
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 action is crucial in assessing the content and severity of the hallucinations, which helps in tailoring appropriate interventions. By directly inquiring about the auditory hallucinations, the nurse demonstrates active listening and shows empathy towards the client's experiences. This approach also fosters a trusting therapeutic relationship.
Choice A: Encouraging the client to lie down in a quiet room does not address the auditory hallucinations directly and may not be effective in managing them.
Choice B: Referring to the hallucinations as if they are real can validate and reinforce the client's delusions, worsening the symptoms.
Choice D: Avoiding eye contact with the client may convey a message of discomfort or disinterest, hindering the establishment of rapport and trust.
In summary, choice C is the most appropriate as it directly addresses the client's symptoms and facilitates a comprehensive assessment, which is essential for developing an effective care plan.
A nurse in an acute care mental health facility is placing a client in seclusion and restraints. Which of the following actions should the nurse plan to take?
- A. Ensure that the prescription for restraints be renewed every 6 hr.
- B. Document the client's behavior every 15 min.
- C. Request a provider to evaluate the client in person every 36 hr.
- D. Plan to monitor the client every 30 min while restrained.
Correct Answer: B
Rationale: The correct answer is B: Document the client's behavior every 15 min. This action is important to ensure the client's safety and monitor their response to seclusion and restraints. Documenting behavior every 15 minutes allows the nurse to track changes, identify any signs of distress, and ensure the client's well-being. It also helps in providing a detailed record of the client's condition for further evaluation and decision-making.
The other choices are incorrect because:
A: Ensuring the prescription for restraints be renewed every 6 hr is not necessary for immediate monitoring and safety.
C: Requesting a provider to evaluate the client in person every 36 hr is not frequent enough for close monitoring and intervention.
D: Planning to monitor the client every 30 min while restrained is not as frequent as every 15 minutes, which may miss important changes in behavior or condition.
A nurse is teaching a client who has generalized anxiety disorder about buspirone. Which statement indicates the client understands the teaching?
- A. I should take this medication as needed for acute anxiety.
- B. I may experience sedation and drowsiness with this medication.
- C. I should avoid grapefruit juice while taking this medication.
- D. This medication has a risk for dependence.
Correct Answer: C
Rationale: The correct answer is C. This is because grapefruit juice can interact with buspirone and increase its concentration in the blood, leading to potential side effects. Choice A is incorrect because buspirone is not meant for acute anxiety but requires regular dosing. Choice B is incorrect as sedation is not a common side effect of buspirone. Choice D is incorrect because buspirone is not associated with dependence or abuse potential.