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A nurse manager is providing staff education about working with clients who have a history of anger and aggression. Which of the following information should the nurse include in the teaching? (Select all that apply.)
- A. Avoid wearing necklaces during client care.
- B. Know the layout of the facility.
- C. Stand directly in front of the client when talking.
- D. Bring security with you for all client interactions.
- E. Provide immediate verbal feedback for escalating behavior.
Correct Answer: A, B, E
Rationale: The correct answers are A, B, and E. A: Wearing necklaces can be used as a weapon or trigger aggressive behavior. B: Knowing the facility layout helps in planning safe exits during an escalating situation. E: Providing immediate verbal feedback can help de-escalate aggressive behavior. C: Standing directly in front of the client can be confrontational. D: Bringing security for all interactions may escalate tension unnecessarily.
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A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE), the nurse should include which of the following data? (Select all that apply.)
- A. Ability to perform calculations
- B. Coping skills
- C. Recall ability
- D. Long-term memory
- E. Level of orientation
Correct Answer: A, C, D, E
Rationale: The correct answers are A, C, D, and E. In a Mental Status Examination for a client with dementia, assessing the ability to perform calculations (A) is important to evaluate cognitive function. Recall ability (C) is crucial as memory impairment is a common feature of dementia. Long-term memory (D) is essential to assess for signs of cognitive decline. The level of orientation (E) is vital to determine the client's awareness of time, place, and person, which can be impaired in dementia. Coping skills (B) are important but not typically assessed in an MSE for dementia. The other choices (F, G) do not directly relate to the cognitive impairment typically seen in dementia.
A nurse is assigning a room to a client who is experiencing a manic episode. Which of the following is the most appropriate room selection?
- A. A room adjacent to the nursing station
- B. A room without a window
- C. A room with dim lighting
- D. A room containing personal belongings
Correct Answer: A
Rationale: A room close to the nursing station allows for close monitoring and quick intervention if necessary.
A nurse is caring for a group of clients. The nurse should recognize that which of the following clients is at risk for a vitamin B deficiency?
- A. A client who takes gabapentin as part of treatment for a seizure disorder.
- B. A client who has asthma.
- C. A client who has chronic alcohol use disorder.
- D. A client who takes heparin to prevent deep vein thrombosis.
Correct Answer: C
Rationale: The correct answer is C: A client who has chronic alcohol use disorder. Chronic alcohol use can lead to malabsorption of essential vitamins, including vitamin B. Alcohol interferes with the absorption and utilization of vitamin B, leading to a deficiency. This can result in various neurological and hematological complications. Clients with chronic alcohol use disorder are at high risk for vitamin B deficiency and should be closely monitored.
Incorrect Choices:
A: Gabapentin is not directly related to vitamin B deficiency.
B: Asthma does not directly increase the risk of vitamin B deficiency.
D: Heparin does not impact vitamin B levels significantly.
A nurse in an acute mental health facility is creating a plan of care for a new client who has histrionic personality disorder. Which of the following is the priority intervention for the nurse to make?
- A. Promote appropriate behavior during group therapy sessions.
- B. Encourage client input in the treatment plan.
- C. Communicate with the client using concrete language.
- D. Demonstrate assertive behavior.
Correct Answer: A
Rationale: The correct answer is A: Promote appropriate behavior during group therapy sessions. For a client with histrionic personality disorder, the priority intervention is to establish boundaries and promote appropriate behavior to ensure a therapeutic environment. This is crucial in managing attention-seeking behaviors and maintaining focus on the therapeutic goals. Encouraging client input in the treatment plan (B) is important but not the priority at this stage. Communicating with concrete language (C) may be helpful but does not address the immediate need for behavior management. Demonstrating assertive behavior (D) is not the priority as it may escalate the situation.
A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?
- A. Determining if the client has psychotic thinking
- B. Asking the client to identify the cause of the crisis
- C. Identifying the client's coping skills
- D. Identifying the client's support systems
Correct Answer: A
Rationale: The correct answer is A: Determining if the client has psychotic thinking. This is the highest priority because it directly addresses the client's immediate safety and well-being. Psychotic thinking can pose a significant risk to the client and others, requiring prompt intervention. Asking the client to identify the cause of the crisis (B), identifying coping skills (C), and support systems (D) are important but secondary to ensuring the client's safety. It is crucial to address any potential psychotic thinking first before delving into other aspects of the assessment.