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A nurse on an inpatient mental health unit is caring for a client who has major depressive disorder and malnutrition. Which of the following actions should the nurse take to improve the client's nutritional status?
- A. Enroll the client in a nutritional class on the unit.
- B. Weigh the client at the same time every morning.
- C. Ask the provider to arrange a consultation with the facility chaplain.
- D. Sit with the client during meals and snacks.
Correct Answer: D
Rationale: The correct answer is D: Sit with the client during meals and snacks. This option promotes a therapeutic relationship, encourages the client to eat, and provides emotional support. By sitting with the client, the nurse can monitor food intake, address any eating difficulties, and offer encouragement. This approach helps the client feel supported and valued, which can positively impact their nutritional intake.
Choice A is incorrect as a nutritional class may not address the client's immediate needs. Choice B is incorrect as weighing the client daily does not directly improve their nutritional status. Choice C is incorrect as involving the chaplain may not address the nutritional needs of the client.
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A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?
- A. Experiencing diarrhea
- B. Exercising moderately
- C. Increasing sodium intake
- D. Drinking green tea
Correct Answer: A
Rationale: The correct answer is A: Experiencing diarrhea. Diarrhea can lead to dehydration and electrolyte imbalances, which can increase lithium levels in the blood and cause toxicity. This is because lithium is primarily excreted by the kidneys, and dehydration can impair its elimination. Options B, C, and D are incorrect because moderate exercise, increasing sodium intake, and drinking green tea are not known to directly cause lithium toxicity. In fact, maintaining adequate hydration and a balanced diet with normal sodium intake can help prevent lithium toxicity.
A nurse in an emergency department is assessing a client for suspected cocaine intoxication. Which of the following findings should the nurse expect?
- A. Nystagmus
- B. Dilated pupils
- C. Hypersomnia
- D. Depression
Correct Answer: B
Rationale: The correct answer is B: Dilated pupils. Cocaine intoxication typically presents with dilated pupils due to the drug's stimulant effects on the sympathetic nervous system. This causes pupil dilation by increasing the release of norepinephrine. Nystagmus (choice A) is not a common finding in cocaine intoxication. Hypersomnia (choice C) is unlikely as cocaine is a stimulant that often leads to decreased need for sleep. Depression (choice D) is not a typical symptom of cocaine intoxication. In summary, dilated pupils are a key indicator of cocaine intoxication, while nystagmus, hypersomnia, and depression are not characteristic findings.
A nurse is admitting a client who is about to undergo surgery for benign prostatic hypertrophy. The client states, 'I don't know what I will do if they find I have cancer.' Which of the following responses should the nurse make?
- A. Why do you think you might have cancer when your diagnosis is a benign condition?'
- B. I'm looking at your chart here and I don't see any reason for you to worry about that.'
- C. I think that's something you need to discuss with your provider.'
- D. I'm hearing that you are concerned that it might turn out that you have cancer.'
Correct Answer: D
Rationale: Rationale: The correct response is D because it acknowledges the client's fear and validates their emotions. By reflecting back the client's statement, the nurse shows empathy and understanding. This approach helps build trust and rapport with the client, fostering open communication. Choice A is dismissive and does not address the client's feelings. Choice B is invalidating and can increase the client's anxiety. Choice C deflects the client's emotions instead of addressing them directly. In summary, option D is the best response as it demonstrates active listening and empathy, promoting a therapeutic nurse-client relationship.
A nurse in a rehabilitation center is planning care for a newly admitted client who has a history of alcohol use disorder. Which of the following client goals is the highest priority?
- A. The client will acknowledge alcohol dependence and need for treatment.
- B. The client will rebuild damaged interpersonal relationships.
- C. The client will implement alternative strategies for managing anxiety.
- D. The client's withdrawal from alcohol will be managed without complications.
Correct Answer: D
Rationale: The correct answer is D because managing alcohol withdrawal without complications is the highest priority to ensure the client's safety and well-being. Withdrawal from alcohol can lead to life-threatening complications such as seizures and delirium tremens. Addressing this goal first is crucial for stabilizing the client physically.
Choice A is important but not the highest priority as immediate physical safety takes precedence. Choices B and C are important for overall recovery but do not address the immediate risk of withdrawal complications.
A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband." Which of the following is a therapeutic nursing response?
- A. "Your husband is making really good progress."
- B. "Crying helps us let things out and we feel better."
- C. "Did your husband say something to upset you?"
- D. "Tell me what’s concerning you."
Correct Answer: D
Rationale: Encouraging the spouse to verbalize concerns supports therapeutic communication.