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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
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A nurse is caring for a client who has schizophrenia and is experiencing a hallucination. Which of the following actions should the nurse take?
- A. Act as if the hallucination is real.
- B. Instruct the client to argue with the voices that are a part of the hallucination.
- C. Ask the client direct questions about the hallucination.
- D. Tell the client that the hallucination is not a part of reality.
Correct Answer: C
Rationale: The correct answer is C - Ask the client direct questions about the hallucination. This approach helps the nurse understand the client's experience without validating or denying the hallucination. It shows empathy and promotes trust. Choice A would validate the hallucination, worsening the client's condition. Choice B could escalate the situation by encouraging confrontation with the voices. Choice D may cause the client to feel dismissed or judged. Asking direct questions (C) allows the nurse to gather information, assess the client's safety, and provide appropriate care.
A nurse in a long-term care facility is caring for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
- A. Post a written schedule of daily activities
- B. Use an overhead loudspeaker to announce events
- C. Provide a consistent daily routine
- D. Allow the client to choose free-time activities
Correct Answer: C
Rationale: The correct answer is C: Provide a consistent daily routine. Individuals with Alzheimer's disease benefit from a structured routine as it helps reduce confusion and anxiety. Consistency in daily activities can enhance familiarity and comfort for the client, promoting a sense of security and predictability. This routine can also aid in maintaining the client's cognitive function and overall well-being.
Incorrect choices:
A: Post a written schedule of daily activities - While this may be helpful, a consistent routine is more effective in providing stability for individuals with Alzheimer's.
B: Use an overhead loudspeaker to announce events - Loud noises and sudden announcements can be overwhelming for individuals with Alzheimer's, causing distress.
D: Allow the client to choose free-time activities - While promoting autonomy is important, too many choices can lead to confusion and difficulty in decision-making for individuals with Alzheimer's.
A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the following actions should the nurse take?
- A. Set limits for the relationship
- B. Promote the use of transference by the client
- C. Instruct the client on how he should behave
- D. Engage in friendly interactions with the client
Correct Answer: A
Rationale: The correct answer is A: Set limits for the relationship. In a therapeutic relationship, setting boundaries and limits is crucial to establish a safe and professional environment. This helps the client understand the expectations and maintain appropriate behavior. By setting limits, the nurse can ensure a therapeutic focus and prevent any potential harm or misunderstandings.
Choice B (Promote the use of transference by the client) is incorrect because encouraging transference can lead to unrealistic expectations and hinder the therapeutic process. Choice C (Instruct the client on how he should behave) is incorrect as it undermines the client's autonomy and may create a power dynamic. Choice D (Engage in friendly interactions with the client) is incorrect as it blurs professional boundaries and may lead to a lack of objectivity.
A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (Select all that apply.)
- A. Grooming
- B. Long-term memory
- C. Support systems
- D. Affect
- E. Presence of pain
Correct Answer: A, B, D
Rationale: The correct choices for the nurse to include in the MSE for a client with dementia are A, B, and D. Grooming is important to assess the client's self-care ability, which can be impacted by dementia. Long-term memory is essential in evaluating cognitive decline typically seen in dementia. Affect assessment helps determine emotional responses and can indicate changes in mood associated with dementia. Support systems (choice C) are not typically part of the MSE but are relevant for treatment planning. Presence of pain (choice E) is important but not a traditional component of a mental status examination.
A nurse in an emergency department is assessing a client who has traumatic injuries following an assault. The client sits quietly and calmly in the examination room and states, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions?
- A. Denial
- B. Displacement
- C. Projection
- D. Undoing
Correct Answer: A
Rationale: The correct answer is A: Denial. The client's calm demeanor and statement of "I'm fine" despite having traumatic injuries indicate a defense mechanism of denial, where the client is refusing to acknowledge the severity of their situation. Denial helps the individual cope with overwhelming emotions or stress by avoiding the reality of the situation. Displacement involves redirecting emotions to a less threatening target, projection involves attributing one's thoughts or feelings to others, and undoing involves engaging in behaviors to counteract negative thoughts or actions. In this scenario, denial is the most appropriate reaction based on the client's behavior.