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A nurse is reviewing the laboratory results of a client who is taking lithium. Which of the following values should the nurse report to the provider?
- A. Lithium level 0.6 mEq/L
- B. Sodium 135 mEq/L
- C. Creatinine 1.5 mg/dL
- D. Potassium 4.0 mEq/L
Correct Answer: C
Rationale: The correct answer is C: Creatinine 1.5 mg/dL. Elevated creatinine levels indicate potential kidney damage from lithium toxicity. The nurse should report this value to the provider for further evaluation. Choices A, B, and D are within normal ranges and not directly related to lithium toxicity. Therefore, they do not require immediate attention.
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A nurse is leading a grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression?
- A. I don’t know how I could cope if I didn’t have my family’s support
- B. It’ll be a long time before I’m happy again
- C. I don’t feel anything but numbness anymore
- D. I feel like I’m angry at the whole world right now
Correct Answer: C
Rationale: The correct answer is C: "I don’t feel anything but numbness anymore." This statement indicates a significant emotional numbness, which is a common symptom of clinical depression. It suggests a lack of normal emotional responses, which can be concerning.
Choice A does not specifically indicate clinical depression but rather expresses a need for support. Choice B reflects a natural response to grief and does not necessarily indicate depression. Choice D suggests anger, which can also be a normal part of the grieving process.
In summary, Choice C is the correct answer as it directly points to a key symptom of clinical depression, while the other choices reflect common emotional responses to grief that may not necessarily indicate depression.
A nurse in a community clinic is planning an educational session for a group of clients. Which of the following strategies should the nurse use when teaching about stress management?
- A. Provide lengthy lectures on stress
- B. Encourage discussion and practice of coping skills
- C. Discourage clients from expressing emotions
- D. Teach all clients the same stress-reduction technique
Correct Answer: B
Rationale: The correct answer is B: Encourage discussion and practice of coping skills. This strategy is effective because it actively engages clients in learning and applying coping mechanisms, promoting better retention and skill development. By encouraging discussion, clients can share experiences and support each other, enhancing their understanding and motivation. Practicing coping skills helps clients to internalize and apply them in real-life situations.
Incorrect choices:
A: Providing lengthy lectures is less effective as it can be overwhelming and may not actively involve clients in learning.
C: Discouraging clients from expressing emotions hinders the therapeutic process and can lead to bottling up emotions, increasing stress.
D: Teaching all clients the same technique may not address individual needs and preferences, limiting the effectiveness of stress management strategies.
A nurse is developing a plan of care for a client who has post-traumatic stress disorder. Which of the following interventions should the nurse include?
- A. Encourage the client to suppress traumatic memories
- B. Discourage the client from discussing the trauma
- C. Encourage the client to use relaxation techniques
- D. Limit the client’s participation in activities
Correct Answer: C
Rationale: The correct answer is C: Encourage the client to use relaxation techniques. This is important in managing symptoms of PTSD by helping the client to reduce anxiety and stress levels. Relaxation techniques, such as deep breathing and mindfulness, can help the client cope with distressing thoughts and emotions. Encouraging the client to use these techniques promotes self-soothing and emotional regulation.
Choice A is incorrect because suppressing traumatic memories can worsen symptoms and lead to increased distress. Choice B is incorrect as discussing the trauma in a safe and supportive environment is a key component of PTSD therapy. Choice D is incorrect as limiting activities can hinder the client's recovery process.
A nurse in an alcohol treatment facility is caring for a client who states 'my job is so stressful that the only way I can cope is to drink.' The nurse should recognize that the client is displaying which of the following defense mechanisms?
- A. Repression
- B. Rationalization
- C. Introjection
- D. Intellectualization
Correct Answer: B
Rationale: The correct answer is B: Rationalization. Rationalization is a defense mechanism where individuals justify their behaviors or feelings with logical reasoning or excuses. In this case, the client is justifying their drinking by attributing it to the stress of their job. This defense mechanism helps the individual avoid facing the real underlying issues causing their behavior.
Choice A: Repression involves pushing unwanted thoughts or feelings into the unconscious mind, which is not demonstrated by the client's statement.
Choice C: Introjection is the internalization of external beliefs or values, not applicable in this context.
Choice D: Intellectualization is the process of focusing on facts and logic to avoid dealing with emotions, which is not evident in the client's statement.
A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following actions should the nurse take?
- A. Place the client in a group therapy session
- B. Rotate staff members who work with the client
- C. Encourage the client to participate in physical activities
- D. Distract the client with increased environmental stimuli
Correct Answer: C
Rationale: The correct answer is C: Encourage the client to participate in physical activities. Physical activities can help to channel the excess energy and agitation associated with manic episodes in bipolar disorder. Exercise can help reduce stress, improve mood, and promote better sleep patterns. Group therapy (A) may not be appropriate during a manic episode as the client may have difficulty focusing and could disrupt the session. Rotating staff members (B) could lead to inconsistency in care and may worsen the client's symptoms. Distracting the client with increased environmental stimuli (D) could exacerbate agitation and overstimulation. It is important to provide a structured and safe outlet for the client's energy, hence physical activities are the most appropriate intervention in this scenario.