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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 52-year-old male client in the intensive care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveal no significant change, and the nurse formulates the diagnosis, 'Confusion related to ICU psychosis.' Which intervention would be best to implement?
- A. Move all machines away from the client's immediate area.
- B. Attempt to allay the client's fears by explaining the etiology of his condition.
- C. Cluster care so that brief periods of rest can be scheduled during the day.
- D. Extend visitation times for family and friends.
Correct Answer: C
Rationale: In critical care environments, stressors can lead to isolation and confusion. Providing the client with scheduled rest periods (C) can help alleviate these symptoms. Moving all machines away (A) is impractical as they are often essential. Explaining the condition (B) may not be effective during acute confusion. Extending visitation times (D) can be overwhelming for the client in the ICU.
A 25-year-old female client has been particularly restless, and the nurse finds her trying to leave the psychiatric unit. She tells the nurse, 'Please let me go! I must leave because the secret police are after me.' Which response is best for the nurse to make?
- A. No one is after you; you're safe here.
- B. You'll feel better after you have rested.
- C. I know you must feel lonely and frightened.
- D. Come with me to your room, and I will sit with you.
Correct Answer: D
Rationale: In this scenario, the best response for the nurse is to offer presence and a safe environment without validating the delusion or arguing with the client. By inviting the client to the room and offering to sit with her, the nurse is providing support and reassurance. Choice A is incorrect because directly denying the client's belief may escalate the situation. Choice B is inappropriate as it dismisses the client's concerns without addressing the underlying issue. Choice C acknowledges the client's feelings but does not provide immediate support or safety, unlike Choice D which offers both.
A client with generalized anxiety disorder is being treated with lorazepam (Ativan). What is the most important teaching point for the LPN/LVN to reinforce?
- A. Take the medication on an empty stomach.
- B. Avoid drinking alcohol while taking this medication.
- C. This medication may cause drowsiness, so avoid driving.
- D. You can stop taking the medication once you feel better.
Correct Answer: B
Rationale: The most important teaching point for the LPN/LVN to reinforce is to avoid drinking alcohol while taking lorazepam (Ativan). Alcohol can enhance the sedative effects of lorazepam, increasing the risk of severe side effects and complications. Choice A is incorrect because lorazepam can be taken with or without food. Choice C is not the most critical teaching point, although it is essential to avoid activities that require mental alertness until the effects of the medication are known. Choice D is incorrect because abruptly stopping lorazepam can lead to withdrawal symptoms and should only be done under medical supervision.
A nurse is caring for a client with major depressive disorder who is withdrawn and refuses to participate in group activities. What is the best nursing intervention?
- A. Encourage the client to attend at least one group session.
- B. Respect the client's wish to remain isolated.
- C. Arrange for individual therapy sessions.
- D. Offer the client a list of activities to choose from.
Correct Answer: A
Rationale: Encouraging the client to attend at least one group session is the best nursing intervention in this scenario. By gently encouraging participation, the nurse can help the client start to engage with others, which may gradually improve their mood and social interaction. Choice B, respecting the client's wish to remain isolated, may further exacerbate the client's withdrawal and depression by reinforcing avoidance behavior. Choice C, arranging for individual therapy sessions, can be beneficial but may not address the specific need for social interaction. Choice D, offering a list of activities to choose from, does not directly address the client's difficulty in participating in group activities and may not provide the necessary support in overcoming social withdrawal.
A 35-year-old male client on the psychiatric ward 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: The correct answer is C: low self-esteem. Delusions of persecution, like being poisoned, are often rooted in underlying issues of low self-esteem and trust. Option A is incorrect because the delusion is not necessarily related to early childhood experiences involving authority issues. Option B is incorrect as there is no information provided that suggests the client's delusion is driven by anger about being hospitalized. Option D is incorrect as the delusion is about being poisoned, not a phobic fear of food.