Nokea
A young adult female client is admitted to a psychiatric facility with a medical diagnosis of bulimia nervosa. Which nursing intervention has the highest priority?
- A. Schedule the client for group therapy with other clients with bulimia nervosa.
- B. Assign the client's care to a nurse with relevant experience in eating disorders.
- C. Monitor the client carefully for binging and purging activities.
- D. Assess and report the client's electrolyte status to the healthcare provider.
Correct Answer: D
Rationale: The correct answer is D. Assessing and reporting the client's electrolyte status to the healthcare provider is the highest priority in a client with bulimia nervosa. Electrolyte imbalances, such as hypokalemia and metabolic alkalosis, are common due to purging behaviors associated with bulimia. Monitoring electrolyte levels is crucial to prevent life-threatening complications. Choices A, B, and C are incorrect because while therapy and monitoring for binging activities are important, addressing the electrolyte imbalances caused by purging behaviors takes precedence in the immediate care of a client with bulimia nervosa.
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A client with obsessive-compulsive disorder (OCD) spends hours each day washing their hands. Which nursing intervention is most appropriate initially?
- A. Allow the client to continue the behavior to reduce anxiety.
- B. Set strict limits on the time allowed for handwashing.
- C. Distract the client with other activities.
- D. Encourage the client to participate in a support group.
Correct Answer: A
Rationale: Initially, it is most appropriate to allow the client to continue the behavior to reduce anxiety (A). For clients with OCD, abruptly stopping compulsive behaviors can lead to increased anxiety and distress. Setting strict limits (B) may exacerbate anxiety at first. Distraction with other activities (C) may not address the underlying issue effectively. While support groups (D) can be beneficial, they are typically introduced after establishing trust and gradually working on reducing compulsive behaviors.
A client with a diagnosis of major depressive disorder is prescribed fluoxetine (Prozac). What is the most important side effect for the LPN/LVN to monitor?
- A. Weight gain.
- B. Sexual dysfunction.
- C. Nausea.
- D. Constipation.
Correct Answer: B
Rationale: The correct answer is B: Sexual dysfunction. When monitoring a client taking fluoxetine (Prozac), the LPN/LVN should prioritize observing for sexual dysfunction. This side effect is crucial to monitor as it can significantly impact the client's quality of life and may affect their adherence to the medication. Weight gain (choice A) is a possible side effect of fluoxetine but is not as critical as sexual dysfunction in terms of monitoring. Nausea (choice C) and constipation (choice D) are common side effects of fluoxetine, but they are generally less concerning compared to the impact of sexual dysfunction on the client's well-being and treatment compliance.
A 35-year-old male client on the psychiatric unit of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to his
- A. early childhood experiences involving authority issues.
- B. anger about being hospitalized.
- C. low self-esteem.
- D. phobic fear of food.
Correct Answer: C
Rationale: Psychotic clients often experience delusions due to difficulties with trust and low self-esteem (C). In this case, the client's belief that someone is trying to poison him is likely a manifestation of his underlying issues with trust and self-worth. Building trust and promoting positive self-esteem are essential in caring for such clients. Choices A, B, and D are incorrect because delusions are not primarily related to early childhood experiences involving authority issues, anger about hospitalization, or phobic fear of food. These factors do not directly contribute to the development of delusions in psychotic clients.
A client with schizophrenia is experiencing auditory hallucinations. What is the most appropriate nursing intervention?
- A. Encourage the client to ignore the voices.
- B. Ask the client what the voices are saying.
- C. Distract the client with a new activity.
- D. Tell the client that the voices are not real.
Correct Answer: B
Rationale: Asking the client what the voices are saying is the most appropriate intervention as it helps the nurse assess the content of the hallucinations and the potential risk they may pose. Encouraging the client to ignore the voices (Choice A) may not address the underlying issue or provide valuable information for the nurse. Distracting the client with a new activity (Choice C) may temporarily divert attention but does not address the hallucinations. Telling the client that the voices are not real (Choice D) may invalidate the client's experience and can lead to distrust in the therapeutic relationship.
A client in the mental health unit believes that the food is being poisoned. What intervention(s) would be helpful when attempting to encourage the client to eat? Select one that does not apply.
- A. Use open-ended questions to encourage client dialogue
- B. Offer opinions about the necessity for adequate nutrition
- C. Focus on the client's self-disclosure about food preferences
- D. Identify the reasons the client has for not wanting to eat
Correct Answer: B
Rationale: Using open-ended questions and focusing on the client's self-disclosure about food preferences can help build rapport and trust with the client, encouraging them to eat. Identifying the reasons the client has for not wanting to eat can provide insights into their concerns. However, offering opinions about the necessity for adequate nutrition may come across as imposing views on the client, potentially leading to resistance. This approach may not be as effective in encouraging the client to eat as it could create a power dynamic that hinders the therapeutic relationship.