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A nurse is sitting in the day room at an acute care mental health facility with a group of clients who are watching television. Suddenly, one of the clients jumps up screaming and runs out of the room. Which of the following actions should the nurse take?
- A. Ask the group what they think about the client’s behavior.
- B. Follow the client to determine the cause of the behavior.
- C. Ignore the incident because it is an attention-seeking behavior.
- D. Stay with the group and ask another client to check on the situation.
Correct Answer: B
Rationale: The correct answer is B: Follow the client to determine the cause of the behavior. This is the best course of action as the nurse should prioritize the safety and well-being of the client who exhibited distress. By following the client, the nurse can assess the situation, provide immediate assistance if needed, and ensure the client's safety. This proactive approach allows the nurse to address any potential risks or triggers that may have caused the client to react in such a manner.
Choice A is incorrect because seeking the group's opinion may waste time and delay necessary intervention. Choice C is incorrect as ignoring the incident could lead to a potentially dangerous situation being overlooked. Choice D is also incorrect as asking another client to check on the situation may not ensure the client's safety and well-being. The best approach is for the nurse to directly assess the client's needs and respond accordingly.
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A nurse in the emergency department is caring for a client who reports chest pain, headache, and shortness of breath. He continues to state, “I don't know why my wife left me.” The client receives a diagnosis of anxiety. The nurse realizes the client’s findings support which level of anxiety?
- A. Mild
- B. Moderate
- C. Severe
- D. Panic
Correct Answer: D
Rationale: The correct answer is D: Panic. The client is experiencing severe physical symptoms (chest pain, headache, shortness of breath) and is unable to identify the source of his distress, which indicates a high level of anxiety. Panic level is characterized by overwhelming fear and physical symptoms that can mimic a heart attack. Mild anxiety (A) is characterized by minor discomfort, moderate anxiety (B) involves increased heart rate and muscle tension, and severe anxiety (C) includes more pronounced physical symptoms. In this case, the client's presentation aligns most closely with panic level anxiety.
A nurse is providing teaching for a client who has binge-eating disorder and is morbidly obese. The client has been prescribed orlistat. Which of the following statements indicates to the nurse that the client understands the teaching?
- A. "I will take my dose of orlistat every morning an hour before breakfast."
- B. "I will stop taking orlistat and call my doctor if my urine gets darker in color."
- C. "I will eat a no-fat diet to prevent side effects from the medication."
- D. "I will feel less hungry during meals while I am taking orlistat."
Correct Answer: B
Rationale: The correct answer is B: "I will stop taking orlistat and call my doctor if my urine gets darker in color." This statement indicates understanding because dark urine can be a sign of liver injury, a serious side effect of orlistat. The client recognizing this symptom and knowing to contact the doctor promptly demonstrates comprehension of the medication's potential risks.
A: "I will take my dose of orlistat every morning an hour before breakfast." - This statement does not indicate understanding of the medication's specific instructions.
C: "I will eat a no-fat diet to prevent side effects from the medication." - While a low-fat diet is recommended with orlistat, this statement does not address potential serious side effects.
D: "I will feel less hungry during meals while I am taking orlistat." - This statement does not address the medication's side effects or potential risks.
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 drug and alcohol detoxification center is planning care for a client who has alcohol use disorder. Which of the following interventions should the nurse identify as the priority?
- A. Helping the client identify positive personality traits
- B. Providing for adequate hydration and rest
- C. Confronting the use of denial and other defense mechanisms
- D. Educating the client about the consequences of alcohol misuse
Correct Answer: B
Rationale: The correct answer is B: Providing for adequate hydration and rest. The priority in caring for a client with alcohol use disorder is addressing physical needs like hydration and rest to manage withdrawal symptoms and prevent complications. Hydration helps prevent dehydration and electrolyte imbalances, while rest supports the body's healing process. Choices A, C, and D focus on psychological aspects, which are important but secondary to addressing immediate physical needs. Helping the client identify positive traits can come later in therapy, confronting denial and defense mechanisms can be addressed once the client is stabilized, and educating about consequences is important but not as urgent as ensuring hydration and rest.
A nurse on a crisis hotline is speaking to a client who says, "I just took an entire bottle of amitriptyline." Which of the following responses should the nurse make?
- A. "I'm glad you called, and I want to send an ambulance to help you."
- B. "You must have been feeling pretty depressed to do that."
- C. "Do you know how many pills were in the bottle?"
- D. "Were you trying to kill yourself by taking an overdose?"
Correct Answer: A
Rationale: The correct response is A: "I'm glad you called, and I want to send an ambulance to help you." This answer demonstrates immediate concern for the client's well-being and prioritizes getting them the necessary medical help. It acknowledges the seriousness of the situation and the potential danger of taking an entire bottle of medication. Sending an ambulance ensures that the client receives prompt medical attention, which is crucial in cases of overdose.
Incorrect responses:
B: "You must have been feeling pretty depressed to do that." - This response focuses on the client's emotional state rather than addressing the immediate need for medical assistance.
C: "Do you know how many pills were in the bottle?" - This question does not prioritize the urgency of the situation and does not address the immediate need for medical help.
D: "Were you trying to kill yourself by taking an overdose?" - This response may come off as accusatory and could potentially escalate the situation. It is important to prioritize the client's safety and well-being