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A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting,and now the client is pacing up and down the hallways of the unit. Which of the following actions should the nurse take?
- A. Instruct the client to sit down and stop pacing.
- B. Allow the client to pace alone until physically tired.
- C. Have a staff member escort the client to her room.
- D. Walk with the client at a gradually slower pace.
Correct Answer: D
Rationale: Walking with the client calmly reduces anxiety while providing support.
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A nurse is providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse?
- A. A child whose parents answer questions for the child
- B. A child who has frequent visitors
- C. A child who has a BMI indicating obesity
- D. A child who uses the call light frequently
Correct Answer: A
Rationale: The correct answer is A. When parents answer questions for the child, it may indicate a lack of autonomy or control over their own care, suggesting potential abuse or neglect. This behavior can be a red flag for the nurse to further assess the child's situation. Choices B, C, and D do not necessarily indicate abuse. Frequent visitors could be a sign of social support, obesity may be due to various factors, and using the call light frequently may indicate medical needs rather than abuse. It is essential for the nurse to explore further if a child's autonomy is being compromised.
Medical History
• Diagnosed with anorexia nervosa at age 16.
• Participated in a weight restoration program 1 year ago.
Vital Signs
1200:
• Blood pressure: 99/59 mm Hg
• Temperature: 36.6°C (97.9°F)
• Heart rate: 58/min
• Respiratory rate: 20/min
• Oxygen saturation: 99% on room air
• Weight: 44.5 kg (98.1 lb)
• BMI: 18.5
• Height: 165.1 cm (65 in)
Nurses’ Notes
1200:
• 18-year-old client admitted to inpatient psychiatric unit after passing out at home. Client reports using laxatives and “making myself throw up after eating” for about 6 months.
1330:
• Reviewed client’s medical record and new diagnostic results; determined client is at risk for further health issues.
Diagnostic Results
1330:
• Basic metabolic panel:
o Glucose: 72 mg/dL (74 to 106 mg/dL)
o Calcium: 10.5 mg/dL (9 to 10.5 mg/dL)
o Sodium: 130 mEq/L (136 to 145 mEq/L)
o Potassium: 3.5 mEq/L (3.5 to 5 mEq/L)
o Magnesium: 2.2 mEq/L (1.3 to 2.1 mEq/L)
o Chloride: 100 mEq/L (98 to 106 mEq/L)
o BUN: 31 mg/dL (10 to 20 mg/dL)
o Creatinine: 3.0 mg/dL (0.5 to 1.0 mg/dL)
• Additional labs:
o Thyroxine, free (T4): 0.4 ng/dL (0.8 to 2.8 ng/dL)
A nurse is reviewing the medical record of a client. Exhibits Drag words from the choices below to fill in each blank in the following sentence.
The client is at risk for developing ----------------- and --------------------
.
- A. Heart Failure
- B. Renal Failure
- C. Hypomagnesemia
- D. Hypothyroidism
Correct Answer: B,D
Rationale:
The correct answer is B and D. Renal failure and hypothyroidism are conditions that can put a client at risk for developing various health issues. Renal failure can lead to electrolyte imbalances and fluid overload, increasing the risk of heart failure. Hypothyroidism can affect metabolism and cardiovascular function, also contributing to the risk of heart failure. Hypomagnesemia (choice C) is a condition characterized by low levels of magnesium in the blood and can lead to symptoms like muscle weakness and cardiac arrhythmias; however, it is not directly mentioned as a risk factor in the sentence provided. Heart failure (choice A) is a consequence or potential outcome of the conditions mentioned but is not specifically stated as a risk the client is currently facing in the sentence.
A nurse is reviewing medication records for several clients who have bipolar disorder. The nurse should recognize that which of the following medications are used to treat clients with bipolar disorder? (Select all that apply.)
- A. Valproate (Depakote)
- B. Carbamazepine (Tegretol)
- C. Lithium (Eskalith)
- D. Donepezil (Aricept)
- E. Paroxetine (Paxil)
Correct Answer: A,B,C
Rationale: The correct answer is A, B, and C. Valproate, Carbamazepine, and Lithium are commonly used to treat clients with bipolar disorder. Valproate helps stabilize mood swings, Carbamazepine is effective for manic episodes, and Lithium is a mood stabilizer that reduces the frequency and intensity of manic episodes. Donepezil is used to treat Alzheimer's disease, not bipolar disorder. Paroxetine is an antidepressant used for treating depression and anxiety disorders, not specifically for bipolar disorder. In summary, Valproate, Carbamazepine, and Lithium are the appropriate medications for managing bipolar disorder, while Donepezil and Paroxetine are not typically used for this purpose.
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 highest priority for the nurse?
- A. Encourage client input in the treatment plan.
- B. Communicate with the client using concrete language.
- C. Demonstrate assertive behavior.
- D. Promote appropriate behavior during group therapy sessions.
Correct Answer: B
Rationale: The correct answer is B: Communicate with the client using concrete language. When working with a client with histrionic personality disorder, using concrete language helps to set clear boundaries and prevent misinterpretations. This is crucial in maintaining a therapeutic relationship and managing their behavior effectively. Encouraging client input (choice A) is important but not the highest priority in this case. Demonstrating assertive behavior (choice C) and promoting appropriate behavior in group therapy (choice D) are important but not as immediately crucial as clear communication.
A nurse is planning care for a client who has dependent personality disorder. Which of the following actions should the nurse plan to take?
- A. Monitor the client closely to prevent self-mutilation.
- B. Set limits to prevent exploitation of other clients.
- C. Give positive feedback when the client is assertive with staff or clients.
- D. Discourage flamboyant or seductive behaviors.
Correct Answer: C
Rationale: The correct answer is C: Give positive feedback when the client is assertive with staff or clients. This is because individuals with dependent personality disorder often struggle with low self-esteem and lack of confidence in their own abilities. By providing positive feedback when the client demonstrates assertiveness, the nurse can reinforce and encourage this behavior, ultimately promoting the client's independence and self-confidence.
Choice A is incorrect because monitoring for self-mutilation is more relevant for clients with other mental health disorders such as borderline personality disorder. Choice B is incorrect as setting limits to prevent exploitation is more appropriate for clients with antisocial personality disorder. Choice D is incorrect as discouraging flamboyant or seductive behaviors is more relevant for clients with histrionic personality disorder.