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An antidepressant medication is prescribed for a client who reports sleeping only 4 hours in the past 2 days and weight loss of 9 lbs within the last month. Which client goal is most important to achieve within the first three days of treatment?
- A. Meet scheduled appointment with dietitian.
- B. Sleep at least 6 hours a night.
- C. Understands the purpose of the medication regimen.
- D. Describes the reasons for hospitalization.
Correct Answer: B
Rationale: The correct answer is B: Sleep at least 6 hours a night. Adequate sleep is crucial in the management of depression as it can improve mood, cognition, and overall functioning. Lack of sleep can exacerbate depressive symptoms. Addressing sleep disturbance early can lead to an improvement in the client's overall well-being. Meeting with a dietitian (choice A) may be important for addressing weight loss but is not as urgent as improving sleep. Understanding the purpose of the medication regimen (choice C) is important for long-term treatment adherence but may not be the priority within the first three days. Describing the reasons for hospitalization (choice D) is not directly related to the immediate treatment goal of addressing sleep disturbance.
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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.
To provide effective care for the patient diagnosed with schizophrenia, the nurse should frequently assess for which associated condition? Select all that apply.
- A. Alcohol use disorder
- B. Major depressive disorder
- C. Stomach cancer
- D. Polydipsia
Correct Answer: A
Rationale: The correct answer is A: Alcohol use disorder. Patients with schizophrenia are at higher risk for co-occurring substance use disorders, including alcohol use disorder. Assessing for alcohol use is crucial as it can worsen symptoms and interfere with treatment. Major depressive disorder (B) is a common comorbidity but is not specific to schizophrenia. Stomach cancer (C) is not directly associated with schizophrenia. Polydipsia (D), excessive thirst, can be seen in schizophrenia due to medication side effects but is not a primary associated condition.
Cognitive-behavioral therapy is going well when a 12-year-old patient in therapy reports to the nurse practitioner:
- A. I was so mad I wanted to hit my mother.
- B. I thought that everyone at school hated me. That’s not true. Most people like me and I have a friend named Todd.
- C. I forgot that you told me to breathe when I become angry.
- D. I scream as loud as I can when the train goes by the house.
Correct Answer: B
Rationale: The correct answer is B because it demonstrates cognitive restructuring in cognitive-behavioral therapy. The patient challenges their negative thought ("everyone hates me") with evidence to the contrary ("most people like me and I have a friend named Todd"). This shows progress in changing maladaptive thought patterns.
Choice A indicates potential aggression, choice C suggests poor retention of coping strategies, and choice D implies a maladaptive coping mechanism. Overall, B is the correct choice as it aligns with the goals of cognitive-behavioral therapy to challenge and reframe negative thoughts.
The occupational health nurse is working with a female employee who was just notified that her child was involved in a MVA and taken to the hospital. The employee states, “I can’t believe this. What should I do?” Which response is best for the RN to provide in this crisis?
- A. Tell me what you think should happen.
- B. How serious was the collision?
- C. What do you think you should do?
- D. Call for transportation to the hospital.
Correct Answer: D
Rationale: The correct response is D: Call for transportation to the hospital. In this crisis situation, the most urgent need is for the employee to be with her child at the hospital. By providing transportation, the nurse ensures that the employee can reach her child quickly and offer support. This action demonstrates empathy and prioritizes the employee's immediate needs.
A: Asking the employee what she thinks should happen may not be the most appropriate response in a crisis where decisive action is needed.
B: Inquiring about the seriousness of the collision is secondary to ensuring the employee can reach her child at the hospital.
C: Asking the employee what she thinks she should do puts the onus on her to make a decision when she may be in distress and unable to think clearly.
A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What is the priority nursing problem for admission to the psychiatric unit?
- A. Ineffective sexual patterns.
- B. Impaired environmental interpretation.
- C. Disturbed sensory perception.
- D. Compromised family coping.
Correct Answer: C
Rationale: The correct answer is C: Disturbed sensory perception. The client's delusions and false beliefs indicate a break from reality, which is a hallmark symptom of disturbed sensory perception. This poses a risk to the client's safety and well-being. Ineffective sexual patterns (choice A) and compromised family coping (choice D) may be secondary to the primary issue of distorted perceptions. Impaired environmental interpretation (choice B) is less relevant as the client's issues are more internal. Overall, addressing the disturbed sensory perception is the priority to ensure the client's safety and initiate appropriate treatment.