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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: "I should avoid grapefruit juice while taking this medication." This is because grapefruit juice can interfere with the metabolism of buspirone, leading to increased levels of the medication in the body, potentially causing adverse effects. Choice A is incorrect because buspirone is not typically taken as needed for acute anxiety but rather on a regular schedule. Choice B is incorrect as sedation and drowsiness are not common side effects of buspirone. Choice D is incorrect as buspirone is not associated with a risk for dependence.
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A nurse in an outpatient mental health clinic is assessing an adolescent client. The nurse should expect the adolescent to be in which of the following of Erikson's stages of psychosocial development?
- A. Generativity vs self-absorption
- B. Trust vs mistrust
- C. Intimacy vs isolation
- D. Identity vs role confusion
Correct Answer: D
Rationale: The correct answer is D: Identity vs role confusion. During adolescence, individuals go through Erikson's stage of Identity vs role confusion, where they explore and develop their own sense of self and try to establish a clear identity. This stage typically occurs during the teenage years, when adolescents are trying to figure out who they are, what they believe in, and what roles they want to play in society. This is a crucial period for developing a strong sense of self and personal identity.
Choices A, B, and C are incorrect because they correspond to different stages in Erikson's theory that do not align with the developmental tasks of adolescence. Generativity vs self-absorption is a stage typically seen in middle adulthood, Trust vs mistrust is seen in infancy, and Intimacy vs isolation is seen in early adulthood. These stages do not apply to the adolescent age group and their current developmental needs.
A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?
- A. I can continue to take St. John's wort while taking this medication.
- B. I know it will be a couple of weeks before the medication helps me feel better.
- C. I expect this medication to raise my blood pressure.
- D. I should take this medication on an empty stomach.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
- Choice B indicates an understanding of the delayed onset of action of amitriptyline, which typically takes a couple of weeks to produce therapeutic effects.
- This knowledge is crucial for managing client expectations and adherence to treatment.
- Choices A, C, and D are incorrect:
- A: Taking St. John's wort with amitriptyline can result in serotonin syndrome due to potential drug interactions.
- C: Amitriptyline can actually lower blood pressure, not raise it.
- D: Amitriptyline is usually taken with food to minimize gastrointestinal side effects.
- In summary, choice B reflects the correct understanding of the medication's timeline for efficacy, while the other choices demonstrate misconceptions or potential risks.
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 working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase?
- A. We should discuss resources to implement in your daily life.
- B. Let me show you simple relaxation exercises to manage stress.
- C. We should establish our roles in the initial session.
- D. Let's talk about how you can change your response to stress.
Correct Answer: C
Rationale: Correct Answer: C
Rationale: During the orientation phase of the therapeutic relationship, establishing roles is crucial for setting boundaries and clarifying expectations. This helps build trust and create a safe environment for the client to open up. Discussing resources (A) and relaxation exercises (B) would be more appropriate in later phases once the therapeutic relationship is established. Talking about changing responses to stress (D) may be premature at this stage.
A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state?
- A. "What are the voices telling you?"
- B. "I realize the voices are real to you, but I don't hear anything."
- C. "Have you taken your medication today?"
- D. "How long have you been hearing the voices?"
Correct Answer: A
Rationale: The correct answer is A: "What are the voices telling you?" This response demonstrates active listening, assesses the content of the hallucinations, and helps the nurse understand the client's experience. It allows for further assessment and intervention planning. Choice B dismisses the client's experience, choice C focuses on medication compliance rather than addressing the immediate concern, and choice D addresses the duration of the hallucinations but doesn't address the current situation.