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A nurse on an inpatient eating disorders unit is caring for a client who has anorexia nervosa and has a body mass index of 17.2. Which of the following actions should the nurse take? (Select all that apply.)
- A. Provide the client with small meals frequently.
- B. Monitor the client's weight daily.
- C. Allow the client to choose the meals she will eat.
- D. Stay with the client during meals and for 1 hr afterward.
- E. Offer specific privileges for sustained weight gain.
Correct Answer: A, B, D, E
Rationale: The correct actions are A, B, D, and E.
A: Providing small meals frequently helps prevent overwhelming the client and supports gradual weight restoration.
B: Daily weight monitoring is crucial in tracking progress and ensuring the client's safety.
D: Staying with the client during meals and afterward helps prevent purging behaviors and offers support.
E: Offering privileges for sustained weight gain reinforces positive behavior and motivation for recovery.
Incorrect options:
C: Allowing the client to choose meals may lead to restrictive eating habits and hinder weight restoration.
F: No information given.
G: No information given.
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A nurse is reviewing medication records for several psychiatric clients who have bipolar disorder. Which of the following medications is commonly used to treat bipolar disorder?
- A. Paroxetine
- B. Lithium
- C. Donepezil
- D. Valproate
- E. Carbamazepine
Correct Answer: B
Rationale: The correct answer is B: Lithium. Lithium is a mood stabilizer commonly used to treat bipolar disorder by reducing the frequency and intensity of manic episodes. It helps to balance neurotransmitters in the brain. Paroxetine (A) is an antidepressant, Donepezil (C) is used for Alzheimer's disease, Valproate (D) is another mood stabilizer, and Carbamazepine (E) is an anticonvulsant often used in bipolar disorder. Therefore, the correct choice is Lithium (B) as it specifically targets bipolar symptoms.
A nurse is teaching a newly licensed nurse about appropriate actions to take when a client threatens to harm a specific individual. Which of the following statements by the newly licensed nurse indicates understanding?
- A. "I need to make sure that the potential victim is warned."
- B. "I need to keep the information confidential due to the client's right to privacy."
- C. "I can only discuss the client’s threats with a court order."
- D. "I should verbally report this information to the psychiatrist."
Correct Answer: A
Rationale: The correct answer is A. When a client threatens harm to a specific individual, the appropriate action is to ensure the safety of the potential victim by warning them. This is crucial in preventing harm and fulfilling the nurse's duty to protect life. Option B is incorrect because in cases of potential harm, confidentiality can be breached to protect others. Option C is incorrect as waiting for a court order delays necessary action. Option D is incorrect as immediate action should be taken rather than waiting for a psychiatrist's involvement.
A nurse is caring for a client who is terminally ill and exhibiting signs of impending death. The client's medical record states that the client is a practicing Roman Catholic. Which of the following nursing actions is appropriate?
- A. Offer to make arrangements for the Sacrament of the Sick.
- B. Prepare to stay with the client's body after death until family arrives.
- C. Arrange for a member of the client's faith to bathe the body after death.
- D. Post a sign on the client's door stating, “No Talking.”
Correct Answer: A
Rationale: The correct answer is A: Offer to make arrangements for the Sacrament of the Sick. This is appropriate because the client is a practicing Roman Catholic, and the Sacrament of the Sick is a sacrament in the Catholic faith administered to the sick or dying. Offering to arrange for this sacrament shows respect for the client's religious beliefs and provides spiritual comfort.
Choice B is incorrect because staying with the client's body after death is not necessarily a religious practice and may not align with the client's beliefs. Choice C is incorrect as it assumes the client's faith requires a specific individual to bathe the body, which may not be the case for all Roman Catholics. Choice D is incorrect as it is not relevant to the client's religious needs and may hinder communication during this sensitive time.
A school nurse is speaking to the mother of a 16-year-old male adolescent. The mother has concerns about her son. Which of the following statements by the mother should indicate to the nurse that the adolescent is at risk for suicide?
- A. "His favorite teacher committed suicide a few weeks ago."
- B. "He has slept 9 hours each night for the past 2 years."
- C. "He is very religious and attends services twice a week."
- D. "He spends much of his time with his two school friends."
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The statement "His favorite teacher committed suicide a few weeks ago" indicates exposure to suicide, which is a risk factor for suicidal behavior. This experience can trigger feelings of hopelessness and increase the risk of suicide in adolescents. The mother's concern in this context is valid and should be taken seriously.
Summary:
B: Sleeping 9 hours each night for the past 2 years is not a direct indicator of suicide risk. While changes in sleep patterns can be a sign of depression, it is not as specific as exposure to suicide.
C: Being religious and attending services twice a week is not necessarily an indicator of suicide risk. Religious beliefs can provide comfort and support.
D: Spending time with friends is generally a positive sign of social connectedness, which can be protective against suicide.
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.