Nokea
An emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction would be included in the discharge instructions?
- A. Information regarding shelters
- B. Instructions regarding calling the police
- C. Instructions regarding self-defense classes
- D. Explaining the importance of leaving the violent situation
Correct Answer: A
Rationale: The correct answer is A: Information regarding shelters. Providing information about shelters is crucial in cases of family violence as it ensures the client has a safe place to go after discharge, prioritizing their immediate safety. Option B, instructions regarding calling the police, may be necessary but ensuring a safe place to stay is more immediate. Option C, instructions regarding self-defense classes, may not be appropriate as the priority is to ensure the client's safety rather than teaching self-defense. Option D, explaining the importance of leaving the violent situation, is relevant but providing information on immediate shelter options is the priority.
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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 homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit. Which laboratory finding obtained on admission is most important for the nurse to report to the healthcare provider?
- A. Decreased thyroid stimulating hormone level
- B. Elevated liver function profile
- C. Increased white blood cell count
- D. Decreased hematocrit and hemoglobin levels
Correct Answer: A
Rationale: The correct answer is A: Decreased thyroid stimulating hormone level. Hyperthyroidism causes an increased level of serum thyroid hormones (T3 and T4), which inhibit the release of TSH. In this case, a decreased TSH level can indicate hyperthyroidism, which can present with manic behavior. Elevated liver function profile (B) is not directly related to the manic phase of bipolar disorder. Increased white blood cell count (C) typically indicates an infection or inflammation, not directly related to the manic phase. Decreased hematocrit and hemoglobin levels (D) may suggest anemia but are not as crucial in the context of a manic phase of bipolar disorder.
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 nurse is providing discharge teaching to a client with major depressive disorder who is prescribed fluoxetine (Prozac). What is the most important teaching point for the nurse to include?
- A. You may experience dizziness, so avoid driving.
- B. It may take several weeks to feel the full effect of the medication.
- C. Avoid foods high in tyramine while taking this medication.
- D. Take this medication only when you feel depressed.
Correct Answer: B
Rationale: The correct answer is B because SSRIs like fluoxetine typically take several weeks to reach their full therapeutic effect, so it's important to set realistic expectations for the client. Choice A is incorrect as dizziness is a common side effect but not the most important teaching point. Choice C is incorrect as avoiding tyramine-rich foods is more relevant for MAOIs. Choice D is incorrect as fluoxetine should be taken consistently, not only when the client feels depressed, to maintain therapeutic blood levels.
A client with obsessive-compulsive disorder (OCD) repeatedly checks the locks on the doors. What is the most therapeutic nursing intervention?
- A. Allow the client to continue the behavior to reduce anxiety.
- B. Encourage the client to discuss the thoughts and feelings behind the behavior.
- C. Restrict the client's access to the locks.
- D. Schedule specific times for the client to check the locks.
Correct Answer: B
Rationale: The most therapeutic nursing intervention for a client with obsessive-compulsive disorder (OCD) who repeatedly checks locks is to encourage the client to discuss the thoughts and feelings behind the behavior. By exploring the underlying anxiety and triggers, the client can work towards understanding and managing their compulsions. Choice A is incorrect because allowing the client to continue the behavior does not address the root cause or help modify the behavior. Choice C is inappropriate as restricting access to locks can increase anxiety and worsen symptoms. Choice D of scheduling specific times for checking locks does not address the underlying psychological issues driving the behavior.