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A nursing is advising an assistive personnel (AP) on the care of a client who has major depressive disorder. The AP states that he is irritated by the client’s depression. Which of the following statements by the nurse is appropriate?
- A. Please don’t take what the client said seriously when she is depressed
- B. It’s important that the client feel safe verbalizing how she is feeling
- C. Everybody feels that way about this client so don’t worry about it
- D. I’ll change your assignment to someone who doesn’t have depressive disorder
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Changing the AP's assignment is appropriate because it addresses the issue of the AP's irritation towards the client's depression. It ensures the client's care is not compromised and maintains a supportive environment. This action also prevents negative attitudes from affecting the client's well-being.
Summary of other choices:
A: Incorrect. Minimizing the client's feelings is inappropriate and may invalidate their experiences.
B: Incorrect. While it is important for the client to verbalize feelings, the focus here is on addressing the AP's behavior.
C: Incorrect. Dismissing the AP's feelings and normalizing negative attitudes are not appropriate responses.
E, F, G: Not provided, but based on the context, they are likely to be irrelevant or inappropriate responses.
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A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include?
- A. Provide frequent rest periods
- B. Discourage social interaction
- C. Allow unlimited physical activity
- D. Limit the client's choices
Correct Answer: A
Rationale: The correct answer is A: Provide frequent rest periods. During mania, clients with bipolar disorder have high energy levels and may engage in excessive activities, leading to physical and mental exhaustion. Providing frequent rest periods helps to prevent burnout and promotes relaxation. Choice B is incorrect as social interaction can provide support and prevent feelings of isolation. Choice C is incorrect as unlimited physical activity can exacerbate manic symptoms. Choice D is incorrect as limiting choices can cause frustration and may escalate the manic episode.
A nurse is teaching a client who has schizophrenia about the adverse effects of clozapine. Which of the following side effects should the nurse include in the teaching?
- A. Increased salivation
- B. Tardive dyskinesia
- C. Hypertension
- D. Photosensitivity
Correct Answer: B
Rationale: The correct answer is B: Tardive dyskinesia. Clozapine can lead to this side effect, which is characterized by involuntary movements of the face and body. This is important to include in teaching as it can be a serious and potentially irreversible effect of the medication. Increased salivation (choice A) is not a common side effect of clozapine. Hypertension (choice C) is not typically associated with clozapine use. Photosensitivity (choice D) is not a common side effect of clozapine. Overall, choice B is the correct answer as it aligns with the known side effects of clozapine in individuals with schizophrenia.
A nurse is reviewing laboratory values for a client who has bipolar disorder and a prescription for lithium. Which of the following laboratory results places the client at risk for lithium toxicity?
- A. Calcium 9.0 mg/dL
- B. Sodium 130 mEq/L
- C. Chloride 98 mEq/L
- D. Potassium 5.0 mEq/L
Correct Answer: B
Rationale: The correct answer is B: Sodium 130 mEq/L. Low sodium levels increase the risk of lithium toxicity as lithium competes with sodium for reabsorption in the kidneys. This can lead to higher lithium levels in the bloodstream, putting the client at risk for toxicity. The other choices (A, C, D) are within normal ranges and do not directly impact lithium toxicity. Therefore, the client with low sodium levels is at the highest risk for lithium toxicity.
A nurse is reviewing laboratory findings for a client who is taking valproic acid. Which of the following results should the nurse report to the provider?
- A. Platelets 250,000/mm³
- B. AST 45 units/L
- C. WBC 9,000/mm³
- D. ALT 65 units/L
Correct Answer: D
Rationale: The correct answer is D: ALT 65 units/L. Elevated ALT levels indicate potential liver damage, a known side effect of valproic acid. The nurse should report this to the provider for further evaluation. Platelets, AST, and WBC levels are within normal ranges, so they do not require immediate reporting. In summary, the correct answer is focused on a potential serious side effect related to the medication, while the other choices are not directly linked to valproic acid or indicate normal laboratory values.
A nurse is assessing a client who has histrionic personality disorder. Which of the following findings should the nurse expect?
- A. Lack of remorse
- B. Attention seeking
- C. Splitting of staff
- D. Identity disturbance
Correct Answer: B
Rationale: The correct answer is B: Attention seeking. In histrionic personality disorder, individuals often seek attention by being overly dramatic, seductive, or provocative. This behavior is a key characteristic of the disorder. Lack of remorse (A) is more indicative of antisocial personality disorder. Splitting of staff (C) is more commonly associated with borderline personality disorder. Identity disturbance (D) is a feature of borderline personality disorder as well. In summary, attention seeking behavior is a hallmark trait of histrionic personality disorder, making choice B the correct answer in this scenario.