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An anxious client expressing a fear of people and open places is admitted to the psychiatric unit. What is the most effective way for the nurse to assist this client?
- A. Plan an outing within the second week of admission.
- B. Distract the client whenever they express discomfort about being with others.
- C. Confront the client's fears and discuss the possible causes of these fears.
- D. Accompany the client outside for an increasing amount of time each day.
Correct Answer: D
Rationale: The most effective way to assist a client with a fear of people and open places is through gradual desensitization by controlled exposure to the situation which is feared (D). This method helps the client confront their fears in a safe and supportive manner, allowing them to gradually build confidence and reduce anxiety. Planning an outing within the second week of admission (A) may be too soon and overwhelming for the client. Distracting the client whenever they express discomfort (B) does not address the underlying issue and may promote denial. Confronting the client's fears and discussing possible causes (C) could be too aggressive initially and may not be well-tolerated by the client.
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A client is on a methadone maintenance program for opioid addiction. What is the most important assessment to perform?
- A. Monitor for signs of withdrawal.
- B. Assess for signs of methadone toxicity.
- C. Evaluate the client's respiratory status.
- D. Check the client's blood pressure regularly.
Correct Answer: C
Rationale: The most important assessment to perform for a client on a methadone maintenance program is to evaluate the client's respiratory status. Methadone can cause respiratory depression as a side effect, making it crucial to monitor the client's breathing to prevent potential complications. Monitoring for signs of withdrawal (choice A) is important but not the most critical in this scenario. Assessing for signs of methadone toxicity (choice B) is relevant, but respiratory status takes precedence due to the risk of respiratory depression. Checking the client's blood pressure regularly (choice D) is important for overall assessment but is not as crucial as monitoring respiratory status in this case.
A male employee who is assessed weekly in the employee clinic for blood pressure because of a history of hypertension tells the nurse that he is so upset with one of his co-workers that he would like to shoot him. What action should the nurse take first?
- A. Determine if the client has a weapon available for use.
- B. Inform the health care provider of the threat to harm a co-worker.
- C. Notify security of the client's intention to harm a co-worker.
- D. Have the employee escorted to a mental health facility.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client diagnosed with undifferentiated schizophrenia is being discharged on aripiprazole (Abilify) 5 mg every night. When developing the teaching plan about the most common adverse effects, which of the following should the nurse include? Select one that does not apply.
- A. Headaches that will subside in a few weeks
- B. Transient mild anxiety
- C. Insomnia
- D. Torticollis
Correct Answer: D
Rationale: The correct answer is D: Torticollis. Common side effects of aripiprazole include headaches, mild anxiety, and insomnia. These side effects are manageable during treatment. Torticollis is not a common adverse effect associated with aripiprazole and is more commonly seen with other medications or conditions. Therefore, the nurse should not include torticollis in the teaching plan about the most common adverse effects of aripiprazole.
A client with an eating disorder is planning to attend group meetings with Overeaters Anonymous. The LPN/LVN describes this group to the client, knowing that which finding(s) are characteristic of this form of self-help group? Select one that does not apply.
- A. A common goal is shared by all members
- B. Members are required to remain anonymous
- C. The leader is a professional mental health care provider
- D. Attendance must be prescribed by the health care provider
Correct Answer: A
Rationale: Overeaters Anonymous is a self-help group characterized by shared goals among members to address eating disorders. This provides a supportive environment for personal change and growth. Choice B is incorrect as members are not required to remain anonymous in Overeaters Anonymous. Choice C is incorrect as the leader in such self-help groups is usually a member who has experienced similar issues, not necessarily a professional mental health care provider. Choice D is incorrect as attendance at Overeaters Anonymous meetings is voluntary and not prescribed by a healthcare provider.
A male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon. When the nurse asks the teen to identify his reason for the assault, he replies, 'Because he made me mad!' Which goal is best for the nurse to include in the client's plan of care? The client will
- A. outline methods for managing anger.
- B. control impulsive actions toward self and others.
- C. verbalize feelings when anger occurs.
- D. recognize consequences for behaviors exhibited.
Correct Answer: B
Rationale: In this scenario, the client's response indicates poor impulse control, a common issue in individuals with bipolar disorder. The most critical goal for the nurse to include in the client's plan of care is to help the client control impulsive actions toward self and others. This goal is essential for preventing harmful behaviors and mitigating the social consequences associated with impulsivity. While outlining methods for managing anger, verbalizing feelings when anger occurs, and recognizing consequences for behaviors exhibited are important aspects of therapy, they do not directly address the urgent need to control impulsive behavior in this case.