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An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse take first?
- A. Discuss treatment options for abusive partners.
- B. Explore the client's readiness to discuss the situation.
- C. Determine the frequency and type of client's abuse.
- D. Report the finding to the police department.
Correct Answer: B
Rationale: Exploring the client's readiness to discuss the situation is the correct first step. It allows the nurse to assess the client's emotional state, willingness to seek help, and readiness to address the abusive relationship. This approach helps build trust and rapport with the client, paving the way for further interventions. Discussing treatment options for abusive partners (Choice A) may be premature and not well-received if the client is not ready to address the situation. Determining the frequency and type of abuse (Choice C) is important but not the immediate priority compared to assessing the client's readiness to talk. Reporting the finding to the police (Choice D) should be done if there is an immediate threat to the client's safety, but exploring the client's readiness to discuss the situation should be the initial step to provide support and intervention.
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A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates the nurse's mannerisms. The nurse knows that the client is using which defense mechanism?
- A. Sublimation.
- B. Identification.
- C. Introjection.
- D. Repression.
Correct Answer: B
Rationale: The correct answer is (B) Identification. In this scenario, the client is imitating the nurse's mannerisms, which is a form of identification, a defense mechanism where an individual adopts the characteristics or behaviors of someone they admire or view as powerful. (A) Sublimation involves channeling unacceptable impulses into socially acceptable actions, not imitation. (C) Introjection is the internalization of external qualities or attributes, not imitation. (D) Repression is the unconscious exclusion of painful thoughts or memories from awareness, which is not demonstrated in this case.
A client with obsessive-compulsive disorder (OCD) repeatedly checks the locks on the doors. What is the best nursing intervention?
- A. Encourage the client to discuss their fears.
- B. Limit the client's time for ritualistic behavior.
- C. Assist the client to complete the ritual faster.
- D. Prevent the client from engaging in the behavior.
Correct Answer: A
Rationale: The best nursing intervention when dealing with a client with OCD who repeatedly checks locks is to encourage the client to discuss their fears. This approach can help the client identify underlying anxiety triggers and work towards developing alternative coping mechanisms. Choice B, limiting the client's time for ritualistic behavior, may increase anxiety and worsen symptoms by creating a sense of urgency. Choice C, assisting the client to complete the ritual faster, does not address the underlying issues and may reinforce the behavior. Choice D, preventing the client from engaging in the behavior, can lead to increased anxiety and distress for the client.
A client is responding to auditory hallucinations and shakes a fist at a nurse and says, 'Back off, witch!' The nurse follows the client into the day room. What action should the nurse implement?
- A. Sit down in a chair near the client.
- B. Position self within an arm's length of the client.
- C. Ensure that there is physical space between the nurse and client.
- D. Move to a position that allows the client to be closest to the room's door.
Correct Answer: C
Rationale: In situations where a client is responding to auditory hallucinations and displaying aggressive behavior, it is crucial for the nurse to ensure physical space between themselves and the client. This action can help de-escalate the situation and prevent any potential harm to both the nurse and the client. Sitting down near the client (Choice A) may escalate the situation by invading the client's personal space. Positioning oneself within an arm's length of the client (Choice B) may increase the risk of physical confrontation. Moving closer to the room's door (Choice D) may not be appropriate as it can block the client's exit route and escalate the situation further. Therefore, ensuring physical space between the nurse and the client (Choice C) is the most appropriate action to promote safety and prevent escalation.
A client with schizophrenia is experiencing auditory hallucinations. What is the most appropriate nursing intervention?
- A. Encourage the client to focus on reality-based activities.
- B. Tell the client that the voices are not real.
- C. Ask the client to describe the voices he hears.
- D. Encourage the client to interact with others who are not experiencing hallucinations.
Correct Answer: A
Rationale: The most appropriate nursing intervention for a client with schizophrenia experiencing auditory hallucinations is to encourage the client to focus on reality-based activities. This intervention helps redirect their attention away from hallucinations, promoting engagement with the environment. Choice B is incorrect as telling the client that the voices are not real may invalidate their experiences and worsen the therapeutic relationship. Choice C may increase the client's distress by focusing on the hallucinations. Choice D might not be helpful as interacting with others who are not experiencing hallucinations may not address the client's current needs.
A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the LPN/LVN take?
- A. Notify the healthcare provider immediately and prepare for administration of an antidote.
- B. Notify the healthcare provider of the symptoms prior to the next administration of the drug.
- C. Record the symptoms as normal side effects and continue administration of the prescribed dosage.
- D. Hold the medication and refuse to administer additional amounts of the drug.
Correct Answer: B
Rationale: When a client being treated with lithium carbonate for bipolar disorder develops symptoms like diarrhea, vomiting, and drowsiness, it could indicate lithium toxicity. The appropriate action for the LPN/LVN is to notify the healthcare provider immediately of these symptoms before the next administration of the drug. This prompt communication is crucial to ensure that the healthcare provider can assess the situation, adjust the treatment plan if necessary, and prevent potential complications associated with lithium toxicity. Option A is incorrect because administering an antidote should be based on the healthcare provider's assessment. Option C is incorrect as these symptoms are not normal side effects and could indicate a serious issue. Option D is incorrect because refusing to administer the drug without consulting the healthcare provider could delay necessary interventions.