Nokea
An adult client presents to the community mental health center accompanied by the client's spouse who reports that the client has been acting impulsively. The client has spent a large amount of money lately, made several last-minute decisions to take trips, sleeps only 2 to 4 hours a night, and has lost 33 pounds (15 kg) in the last 2 months. Which nursing problem has the greatest nursing priority?
- A. Sleep deprivation related to state of hyperactivity.
- B. Ineffective coping related to biochemical changes.
- C. Risk for self-directed violence related to impulsive behavior.
- D. Imbalanced nutrition related to caloric expenditure.
Correct Answer: C
Rationale: The client's impulsive behavior increases the risk of self-directed violence, making it the most urgent nursing priority due to potential immediate harm.
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The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?
- A. A young woman who suddenly goes blind with no indication of organic pathology.
- B. An older adult who continuously complains of a headache and back pain.
- C. An adolescent who becomes extremely anxious about going outside.
- D. A middle-aged man who is complaining of shortness of breath and is diaphoretic.
Correct Answer: A
Rationale: Sudden blindness with no organic pathology is indicative of a conversion disorder, involving neurological symptoms without a neurological basis.
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.
- B. Lithium.
- C. Benztropine.
- D. Magnesium.
Correct Answer: C
Rationale: Benztropine is used to manage extrapyramidal symptoms associated with antipsychotics, so it should be discontinued if the antipsychotic is stopped.
An adolescent male who was arrested a month ago for gang-related activities has a court order to attend weekly group therapy sessions at the mental health clinic. Today his mother calls the clinic nurse to report that her son became angry last night and put his fist through a window. Which intervention is most important for the nurse to implement?
- A. Advise the mother to call the police if violent behavior occurs again.
- B. Refer the mother for psychiatric evaluation for anxiety and depression.
- C. Reinforce the need for the adolescent to attend group therapy sessions.
- D. Tell the mother to describe her feelings of helplessness to her son.
Correct Answer: A
Rationale: Advising the mother to call the police if violent behavior occurs again addresses the safety of the client and others, ensuring appropriate intervention.
A client is admitted to an inpatient psychiatric unit, and the antipsychotic medication clozapine is prescribed. Which intervention should the nurse include in this client's plan of care?
- A. Inform unlicensed assistive personnel (UAP) that the client will likely complain of a sore throat and fever.
- B. Place the client in protective isolation for the first two weeks of treatment with this medication.
- C. Offer this medication to the client with food to decrease the possibility of gastric upset.
- D. Report findings from the client's weekly white blood cell (WBC) counts to the healthcare provider.
Correct Answer: D
Rationale: Clozapine is associated with the risk of agranulocytosis, so regular monitoring of WBC counts and reporting findings to the healthcare provider is essential.
The nurse is leading a group on the inpatient psychiatric unit. Which approach should the nurse use during the working phase of group development?
- A. Helping clients identify areas of problem in their lives.
- B. Discussing ways to use new coping skills learned.
- C. Establishing a rapport with group members.
- D. Clarifying the nurse's role and clients' responsibilities.
Correct Answer: B
Rationale: Discussing ways to use new coping skills learned is appropriate during the working phase, focusing on problem-solving and achieving goals identified earlier.