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A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?
- A. Ask the client to describe and identify the source of the feelings
- B. Provide education about ways to cope with anxiety
- C. Assist the client with relaxation techniques in the group
- D. Escort the client from the group to reduce stimuli
Correct Answer: C
Rationale: Assisting the client with relaxation techniques in the group is the best intervention as it provides immediate support and can help alleviate the client's anxiety in the moment. Exploring the source of anxiety may not be suitable during a group session where immediate relief is needed. Education on coping mechanisms is valuable but does not address immediate needs. Escorting the client out may be considered if anxiety becomes overwhelming, but it is secondary to attempting in-group relaxation.
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A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone. When the client walks to the nurse's station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?
- A. Administer the prescribed anticholinergic benztropine for dystonia
- B. Offer the client a prescribed physical therapy hot pack for muscle spasms
- C. Direct the client to occupational therapy to distract him from somatic complaints
- D. Medicate the client with the prescribed antipsychotic thioridazine
Correct Answer: A
Rationale: The client's laterally contracted position and perception of contortion suggest acute dystonia, a side effect of risperidone. Benztropine, an anticholinergic, alleviates dystonia. Hot packs, occupational therapy, or thioridazine do not address this acute reaction.
In conducting the initial assessment of a preoperative client, the nurse notes that the client's home medications include the monoamine oxidase (MAO) inhibitor phenelzine. Because of this client's medication history, which assessment finding is most important for the nurse to monitor?
- A. Blood pressure
- B. Urinary output
- C. Respiratory rate
- D. Temperature
Correct Answer: A
Rationale: MAO inhibitors like phenelzine can cause hypertensive crises, especially with certain foods or medications. Monitoring blood pressure is critical to detect this life-threatening complication. Urinary output, respiratory rate, and temperature are less directly affected by MAO inhibitors.
A client is admitted to the mental health unit with a bipolar disorder. When seeking to establish a therapeutic relationship and interacting with the client, which comment is best for the nurse to make?
- A. I understand that you're angry and unhappy. Let's explore ways in which you overreact
- B. I hear your frustration about losing control. Tell me how this affects your daily life
- C. Knowing the cause of your symptoms will make them easier to handle
- D. Do all that you can to learn all that you can while you are here. You can get better
Correct Answer: B
Rationale: This response acknowledges the client's feelings and invites further exploration, fostering a therapeutic relationship. The first option may invalidate feelings by assuming overreaction. The third shifts focus from immediate concerns. The fourth is encouraging but does not address current feelings.
The nurse is performing intake interviews at a psychiatric clinic. A client with a known history of drug abuse reports having had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction?
- A. Alcohol
- B. Benzodiazepine
- C. Methamphetamine
- D. Marijuana
Correct Answer: C
Rationale: Methamphetamine use is known to cause significant cardiovascular effects, including increased heart rate, blood pressure, and vasoconstriction, which can lead to myocardial infarction. Excessive alcohol consumption can contribute to cardiovascular issues but is less potent than methamphetamine. Benzodiazepines primarily affect the central nervous system, not the cardiovascular system. Marijuana has cardiovascular effects but is generally less risky than methamphetamine.
During the admission assessment to the mental health unit, a client reports that the people at the office, where the client works, are antagonistic and the client is thinking of shooting the supervisor. The client asks the nurse not to reveal this to anyone else. The nurse immediately notifies the client's therapist and other team members of the client's thoughts. The therapist then calls the client's supervisor and shares the client's thoughts about shooting the supervisor. Which outcome is best based on the action of the nurse?
- A. The nurse is reprimanded for divulging confidential patient information without obtaining informed consent
- B. Both the nurse and therapist are reprimanded for divulging confidential patient information to others
- C. The nurse and therapist will be asked to educate other team members on appropriate sharing of client information
- D. The therapist is reprimanded for divulging confidential patient information without obtaining consent
Correct Answer: C
Rationale: The nurse appropriately shared the threat with the team to ensure safety, but the therapist's disclosure to the supervisor may breach confidentiality. Educating team members on appropriate information sharing balances safety and privacy. Reprimands are less constructive unless clear violations occurred.