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A nurse is reviewing laboratory findings for a client who is taking valproic acid. Which of the following results should the nurse report to the provider?
- A. Platelets 250,000/mm³
- B. AST 45 units/L
- C. WBC 9,000/mm³
- D. ALT 65 units/L
Correct Answer: D
Rationale: The correct answer is D: ALT 65 units/L. Elevated ALT levels indicate potential liver damage, a known side effect of valproic acid. The nurse should report this to the provider for further evaluation. Platelets, AST, and WBC levels are within normal ranges, so they do not require immediate reporting. In summary, the correct answer is focused on a potential serious side effect related to the medication, while the other choices are not directly linked to valproic acid or indicate normal laboratory values.
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A nurse is planning care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following interventions should the nurse include?
- A. Encourage the client to listen to loud music
- B. Ask the client directly about the content of the hallucinations
- C. Instruct the client to ignore the voices
- D. Avoid discussing the hallucinations with the client
Correct Answer: B
Rationale: The correct answer is B: Ask the client directly about the content of the hallucinations. This intervention is important as it helps the nurse understand the nature and content of the hallucinations, allowing for better assessment and tailored intervention. By directly asking the client, the nurse can gather valuable information to provide appropriate care and support. Encouraging the client to listen to loud music (A) may exacerbate the hallucinations. Instructing the client to ignore the voices (C) may not be effective and could lead to increased distress. Avoiding discussing the hallucinations with the client (D) hinders the therapeutic communication and understanding of the client's experience.
A nurse in an inpatient mental health facility is planning care for a client who has schizophrenia and is experiencing delusions. Which of the following interventions should the nurse include?
- A. Encourage the client to focus on reality-based topics
- B. Agree with the client’s delusional beliefs
- C. Discuss the delusions in detail
- D. Provide frequent reassurance about safety
Correct Answer: A
Rationale: The correct answer is A: Encourage the client to focus on reality-based topics. This intervention is appropriate because it helps the client ground themselves in reality and potentially reduce the intensity of their delusions. By redirecting the client's focus to reality-based topics, the nurse can help them challenge and eventually overcome their delusions. Choices B, C, and D are incorrect. Agreeing with delusional beliefs can reinforce them, discussing delusions in detail may exacerbate them, and providing frequent reassurance about safety may not address the underlying issue of delusions.
A nurse in a mental health facility is caring for a client who has borderline personality disorder. Which of the following findings should the nurse expect?
- A. Persistent mood swings
- B. Hypersomnia
- C. Avoidance of eye contact
- D. Ritualistic behaviors
Correct Answer: A
Rationale: The correct answer is A: Persistent mood swings. Borderline personality disorder is characterized by unstable emotions, leading to frequent and intense mood swings. This is a hallmark feature of the disorder. Hypersomnia (choice B) is not typically associated with borderline personality disorder. Avoidance of eye contact (choice C) is more commonly seen in conditions like social anxiety disorder. Ritualistic behaviors (choice D) are more characteristic of obsessive-compulsive disorder, not borderline personality disorder. In summary, persistent mood swings are a key feature of borderline personality disorder, distinguishing it from the other options provided.
A nurse in a psychiatric unit is planning care for a client who has paranoid personality disorder. Which of the following interventions should the nurse include?
- A. Encourage group therapy participation
- B. Avoid challenging the client’s paranoid beliefs
- C. Maintain eye contact during conversations
- D. Use humor to reduce the client’s anxiety
Correct Answer: B
Rationale: The correct answer is B: Avoid challenging the client’s paranoid beliefs. This is essential because challenging the client's beliefs can lead to increased defensiveness and mistrust. Instead, the nurse should validate the client's feelings without reinforcing the delusions. Encouraging group therapy (choice A) may exacerbate paranoia by increasing feelings of being scrutinized. Maintaining eye contact (choice C) may be perceived as threatening. Using humor (choice D) could be misinterpreted and lead to further distrust.
A nurse is caring for a client who is involuntarily admitted for major depressive disorder and refuses to take prescribed antianxiety medication. Which of the following actions should the nurse take?
- A. Inform the client that he does not have the right to refuse medication
- B. Administer the medication to the client via IM injection
- C. Offer the client the medication at the next scheduled dose time
- D. Implement consequences until the client takes the medication
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Implementing consequences until the client takes the medication is the most appropriate action as the client is involuntarily admitted. This approach ensures the client's safety and well-being by addressing the refusal to take prescribed medication. Administering medication via IM injection (B) may escalate the situation and violate the client's rights. Informing the client that he does not have the right to refuse medication (A) is inaccurate and may lead to resistance. Offering the medication at the next scheduled dose time (C) does not address the client's refusal.