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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: The correct answer is C: "We should establish our roles in the initial session." During the orientation phase of the therapeutic relationship, it is crucial to clarify the roles of both the nurse and the client to establish boundaries and expectations. This helps set the foundation for a trusting and effective therapeutic alliance. Discussing resources (A) and relaxation exercises (B) are important but typically occur later in the relationship. Talking about changing responses to stress (D) may be premature in the orientation phase. The other choices are not relevant to the specific goal of the orientation phase, which is to define roles and expectations.
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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. Adolescents typically fall into this stage, characterized by exploring and establishing their sense of self and identity. They may question their roles and values, seeking to understand who they are. Choice A (Generativity vs self-absorption) is more relevant to middle adulthood. Choice B (Trust vs mistrust) is for infancy. Choice C (Intimacy vs isolation) is for young adulthood.
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.
A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
- A. Replace the carpet with hardwood floors.
- B. Encourage physical activity prior to bedtime.
- C. Wear clothing with zippers instead of buttons.
- D. Place locks at the tops of exterior doors.
Correct Answer: D
Rationale: The correct answer is D: Place locks at the tops of exterior doors. This is important for the safety of a client with Alzheimer's disease who may wander and get lost. Placing locks at the tops of exterior doors can help prevent the client from leaving the house unsupervised, reducing the risk of harm. Other choices are incorrect because: A: Replacing carpet with hardwood floors may not directly address safety concerns. B: Encouraging physical activity prior to bedtime may disrupt sleep patterns. C: Wearing clothing with zippers instead of buttons is a personal preference and not directly related to safety.
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: The correct answer is B: "I know it will be a couple of weeks before the medication helps me feel better." This statement indicates an understanding of the teaching because amitriptyline, a tricyclic antidepressant, typically takes a few weeks to reach its full therapeutic effect in treating depressive symptoms. This indicates the client understands the delayed onset of action of the medication.
Incorrect options:
A: "I can continue to take St. John's wort while taking this medication." - St. John's wort can interact with amitriptyline, leading to potentially dangerous side effects.
C: "I expect this medication to raise my blood pressure." - Amitriptyline can indeed cause orthostatic hypotension, not raise blood pressure.
D: "I should take this medication on an empty stomach." - Amitriptyline is usually taken with food to minimize gastrointestinal side effects.
A nurse is assessing a client who has bipolar disorder and is experiencing a depressive episode. Which of the following findings should the nurse expect?
- A. Inability to carry out a simple task
- B. Client reports auditory hallucinations
- C. Moves quickly from one idea to the next
- D. Client expresses illusions of grandeur
Correct Answer: A
Rationale: The correct answer is A: Inability to carry out a simple task. During a depressive episode in bipolar disorder, clients often experience symptoms such as psychomotor retardation, low energy, and difficulty concentrating. This can lead to an inability to carry out simple tasks due to lack of motivation and feelings of worthlessness. Clients may struggle with daily activities and find it challenging to complete even basic tasks. This is a common symptom of depression in bipolar disorder.
Choice B is incorrect as auditory hallucinations are more commonly associated with psychotic disorders or schizophrenia. Choice C is incorrect as rapid speech and jumping from one idea to the next are more indicative of a manic episode in bipolar disorder. Choice D is incorrect as expressing illusions of grandeur is a symptom of mania, not depression.