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A patient with acute mania dances atop a pool table, waves a cue in one hand, and says, "I'll throw the pool balls if anyone comes near me." The nurse's first intervention is to:
- A. Tell the patient
- B. ""We are taking you to seclusion.""
- C. Remove the patient from the pool table.
- D. Clear the room of all other patients.
Correct Answer: B
Rationale: The correct answer is B because taking the patient to seclusion ensures safety for both the patient and others. This intervention controls the immediate risk of harm from the patient's unpredictable behavior. Telling the patient (choice A) may escalate the situation. Removing the patient from the pool table (choice C) may not address the underlying threat. Clearing the room of all other patients (choice D) is not the priority; ensuring immediate safety is paramount in this scenario.
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A client with schizophrenia is medication compliant and has well-controlled symptoms. He has, however, never been successful in holding a job because of poor social skills and lack of understanding of basic job skills. The nurse case manager should consider referring the client:
- A. To a day hospital program
- B. For psychosocial rehabilitation
- C. For cognitive therapy
- D. To assertiveness training
Correct Answer: B
Rationale: The correct answer is B: For psychosocial rehabilitation. This option is the best choice as it focuses on improving the client's social skills and job-related abilities through structured programs. Psychosocial rehabilitation helps individuals with mental health conditions develop the necessary skills for successful integration into the community, including job skills training and social skill development. Referring the client to a day hospital program (A) may not address the specific needs related to job skills and social skills. Cognitive therapy (C) primarily focuses on addressing cognitive distortions and may not directly target the client's social and job-related deficits. Assertiveness training (D) may be helpful, but it may not address the broader range of skills needed for successful job placement and retention.
A nurse is caring for a patient with bulimia nervosa. What should the nurse do to promote a healthy eating pattern?
- A. Provide a strict, rigid eating schedule without flexibility.
- B. Allow the patient to choose meals without any guidelines.
- C. Encourage regular meals and snacks with a focus on nutrition.
- D. Promote food restriction to avoid feelings of guilt after eating.
Correct Answer: C
Rationale: The correct answer is C because encouraging regular meals and snacks with a focus on nutrition helps stabilize blood sugar levels, reduce binge eating episodes, and promote overall health. This approach also supports the patient in developing a balanced relationship with food.
A: Providing a strict, rigid eating schedule may increase anxiety and reinforce unhealthy behaviors.
B: Allowing the patient to choose meals without guidelines may lead to erratic eating patterns and poor nutrition.
D: Promoting food restriction can exacerbate feelings of guilt and perpetuate the cycle of binge eating.
According to family systems theory, removing the 'identified patient' from the environment most likely causes the:
- A. patient to decompensate, due to the loss of their support system
- B. patient to significantly improve, often with minimal or no additional therapy
- C. remaining family members to decompensate, as evidenced by new dysfunctional behavior
- D. remaining family members to lose motivation and withdraw from therapy
Correct Answer: C
Rationale: Family systems theory posits that removing the 'patient' shifts dysfunction to other members, revealing underlying systemic issues.
A female client with a psychotic disorder is experiencing olfactory hallucinations. Most likely, she would be complaining of:
- A. A vision that is disturbing to her
- B. A sound that is disturbing to her
- C. A smell that is disturbing to her
- D. A sense of touch that is disturbing to her
Correct Answer: C
Rationale: The correct answer is C because olfactory hallucinations involve perceiving smells that are not actually present. In a psychotic disorder, such hallucinations are common and can be disturbing to the individual. This is due to the sensory perception of smells that others cannot detect. Choices A, B, and D do not align with the experience of olfactory hallucinations. Vision (A) and sound (B) are not related to olfactory hallucinations, and a sense of touch (D) is not typically associated with this type of sensory distortion in psychotic disorders.
A child, aged 11 years, stays home from school to care for his siblings while his mother works, because the family cannot afford a babysitter. The home is cluttered and dirty when the community mental health nurse visits to investigate the child's school absences. The nurse's legal responsibility if child abuse or neglect is suspected is to:
- A. consult with the child's teacher, principal, and school psychologist.
- B. document the observations and impressions in the family health record.
- C. report her suspicions of abuse or neglect according to state regulations.
- D. wait until she has proof of abuse or neglect, then report it to authorities.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. **Legal Obligation**: The nurse has a legal duty to report suspicions of child abuse or neglect.
2. **Protecting the Child**: Reporting ensures the child's safety and well-being.
3. **State Regulations**: State laws mandate reporting suspected abuse or neglect.
4. **Immediate Action**: Waiting for proof delays intervention and puts the child at risk.
Summary:
- Choice A: Consulting with school staff doesn't fulfill the legal obligation to report.
- Choice B: Documenting is important but not sufficient; reporting is crucial.
- Choice D: Waiting for proof is dangerous; immediate reporting is necessary to protect the child.