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A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment, the client tells the RN that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the RN to provide?
- A. Unless your sister has a medical education, ignore her comments.
- B. I can hear that your sister comments are over-whelming you.
- C. Do you think it’s possible that you might be a hypochondriac?
- D. Besides your sister’s comments, what in your life is troubling you?
Correct Answer: B
Rationale: The correct answer is B: "I can hear that your sister's comments are overwhelming you." This response acknowledges the client's feelings and shows empathy, validating her experience. It demonstrates active listening and understanding without judgment. Choice A dismisses the client's feelings, which can be harmful. Choice C may come off as accusatory and may make the client defensive. Choice D shifts the focus away from the client's emotions, missing an opportunity for therapeutic communication.
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The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued?
- A. Alprazolam (Xanax)
- B. Benztropine (Cogentin)
- C. Magnesium (Milk of Magnesia)
- D. Lithium (Lithotabs)
Correct Answer: B
Rationale: The correct answer is B: Benztropine (Cogentin). Benztropine is a medication commonly used to treat extrapyramidal side effects caused by antipsychotic medications. If the antipsychotic medication is discontinued, there is no longer a need for Benztropine. Alprazolam (A) is used to treat anxiety and should not be automatically discontinued. Magnesium (C) is a laxative and unrelated to bipolar disorder treatment. Lithium (D) is a mood stabilizer commonly used in bipolar disorder treatment and should not be discontinued without a healthcare provider's guidance.
The nurse administers each of the following drugs to various patients. The patient who should be most carefully assessed for fluid and electrolyte imbalance is the one receiving:
- A. Lithium (Eskalith)
- B. Clozapine (Clozaril)
- C. Diazepam (Valium)
- D. Amitriptyline
Correct Answer: A
Rationale: The correct answer is A: Lithium (Eskalith). Lithium is known to cause nephrogenic diabetes insipidus, leading to excessive urination and potential dehydration. Therefore, the patient receiving lithium should be carefully assessed for fluid and electrolyte imbalances. Clozapine (B), Diazepam (C), and Amitriptyline (D) do not have a significant impact on fluid and electrolyte balance compared to lithium.
The RN on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the RN implement the evening before the scheduled ECT?
- A. Hold all bedtime medications.
- B. Keep the client NPO after mid-night.
- C. Implement elopement precautions.
- D. Give the client an enema at bedtime.
Correct Answer: B
Rationale: The correct answer is B: Keep the client NPO after midnight. This is important to prevent aspiration during ECT, as anesthesia is often used and the client must have an empty stomach. Holding all bedtime medications (choice A) is not necessary unless specified by the healthcare provider. Implementing elopement precautions (choice C) is not relevant to ECT procedure. Giving the client an enema at bedtime (choice D) is unnecessary and not indicated for ECT preparation.
When preparing to administer to domestic violence screening tool to a female client, which statement should the RN provide?
- A. If your partner is abusing you, I need to ask these questions.
- B. State law mandates that I ask if you are a victim of domestic violence.
- C. The HCP provider needs to know if you are experiencing any domestic abuse.
- D. All clients are screened for domestic abuse because it is common in our society.
Correct Answer: D
Rationale: The correct answer is D. By stating that all clients are screened for domestic abuse because it is common in society, the nurse normalizes the screening process and reduces stigma. This approach can help the client feel more comfortable disclosing abuse. Choice A may inadvertently imply that the client's partner is abusing them, potentially leading to a defensive response. Choice B may make the client feel obligated to disclose abuse due to legal reasons, which can feel coercive. Choice C is vague and may not convey the importance of screening for domestic violence.
A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the deceased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time?
- A. Not sleeping for several days.
- B. Wishing to be with spouse.
- C. Lack of interest in usual activities.
- D. Eating very little.
Correct Answer: A
Rationale: The correct answer is A: Not sleeping for several days. This is the most important client statement to explore because it indicates the client may be experiencing severe sleep disturbances, which can have a significant impact on their mental and physical health. Lack of sleep can exacerbate symptoms of depression and increase the risk of self-harm or suicide. Therefore, the RN should prioritize exploring this issue to assess the client's safety and provide appropriate interventions.
Choices B, C, and D are also important concerns related to grief and depression, but the immediate risk associated with severe sleep deprivation makes option A the most critical to address first. It is essential to address all client statements eventually, but the urgency of the client's sleep disturbances requires immediate attention.