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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 interact with buspirone and increase the risk of side effects. Option A is incorrect because buspirone is usually taken regularly, not as needed. Option B is incorrect because sedation and drowsiness are uncommon side effects of buspirone. Option D is incorrect because buspirone is not associated with dependence or abuse potential.
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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 crucial in ensuring the safety and well-being of the client in seclusion and restraints. Documenting the client's behavior every 15 minutes allows the nurse to monitor for any changes in the client's condition, response to the intervention, or signs of distress. It helps in identifying any potential risks or improvements, enabling timely intervention or adjustment of the care plan. This frequent documentation also ensures compliance with regulatory standards and serves as a detailed record of the client's status during the intervention.
Other choices are incorrect:
A: Ensuring prescription renewal every 6 hours may be too frequent and not necessary unless there are specific indications.
C: Requesting a provider evaluation every 36 hours may not provide timely assessment and intervention in case of any changes in the client's condition.
D: Monitoring the client every 30 minutes while restrained may not be frequent enough to detect sudden changes or risks promptly.
A nurse is admitting a client who has dementia to a long-term care facility. The client tells the nurse that she lived in this facility years ago and took care of all the residents by herself. The nurse should document this as which of the following findings?
- A. Projection
- B. Perseveration
- C. Agnosia
- D. Confabulation
Correct Answer: D
Rationale: The correct answer is D: Confabulation. Confabulation is the unintentional fabrication of memories or events to fill in gaps in memory due to cognitive impairment. In this scenario, the client with dementia is creating false memories of taking care of all the residents by herself, which is a classic example of confabulation. This behavior is not intentional lying but a result of memory deficits.
Choice A: Projection involves attributing one's own unacceptable feelings or thoughts to others, which is not applicable in this context.
Choice B: Perseveration is the repetition of a particular response, such as repeating a word or phrase, which does not align with the client's false memory.
Choice C: Agnosia refers to the inability to recognize familiar objects or people due to brain damage, which is not evident in the client's statement.
A nurse is planning care for a client who has borderline personality disorder and engages in self-mutilation. Which intervention should the nurse include?
- A. Restrict the client's access to personal belongings.
- B. Encourage the client to express feelings of anger.
- C. Place the client in seclusion when self-injurious behavior occurs.
- D. Tell the client to stop the self-mutilation behavior.
Correct Answer: B
Rationale: The correct answer is B: Encourage the client to express feelings of anger. This intervention helps the client explore and address underlying emotions driving self-mutilation, promoting self-awareness and healthier coping mechanisms. Option A may escalate feelings of lack of control, triggering more self-harm. Option C isolates the client, worsening feelings of abandonment. Option D is dismissive and oversimplifies the behavior.
A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)
- A. Give the client one simple direction at a time.
- B. Refute the client's delusions using logic.
- C. Allow the client to choose among a variety of activities each day.
- D. Reinforce orientation to time, place, and person.
- E. Establish eye contact when communicating with the client.
Correct Answer: A, D, E
Rationale: Correct Answer: A, D, E
Rationale:
A: Giving the client one simple direction at a time is important as individuals with dementia may have difficulty processing complex information.
D: Reinforcing orientation to time, place, and person helps maintain the client's sense of reality and reduce confusion.
E: Establishing eye contact when communicating with the client promotes engagement and helps in maintaining their attention.
Summary:
B: Refuting the client's delusions using logic can be counterproductive as it may cause distress and worsen their symptoms.
C: Allowing the client to choose among a variety of activities may overwhelm them. It is better to provide structured activities.
F & G: Not applicable.
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.