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An older man with a history of multiple falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become increasingly abusive since his release from prison six weeks ago. Which intervention is most important for the nurse to implement?
- A. Tell the client to call Adult Protective Services if his son's abuse continues.
- B. Verify the client's report by determining if there is physical evidence of abuse.
- C. Refer the client to a program for victims of domestic violence.
- D. Assist the client in developing an emergency safety plan.
Correct Answer: D
Rationale: Assisting the client in developing an emergency safety plan is the most important intervention to ensure immediate safety in the context of ongoing abuse.
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A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?
- A. Administer disulfiram immediately.
- B. Place in a side-lying position with the head of the bed elevated.
- C. Give lorazepam PRN for signs of withdrawal.
- D. Provide thiamine and folate supplements as prescribed.
Correct Answer: B
Rationale: Placing the client in a side-lying position with the head elevated prevents aspiration and maintains airway patency, critical for a client with altered consciousness.
When a male client is asked about his reason for coming to the mental health clinic, he replies, “It all started because I work in a hostile work environment. My boss would not let me go to a religious service, so I went to human resources, and they didn't want to do anything. It has been a really difficult time for me.†Which response should the nurse provide?
- A. Why do you think you have a hostile work environment?
- B. Have you considered resigning from your position?
- C. Have the feelings associated with these events brought you to the clinic?
- D. How have you responded to those in your work environment about these events?
Correct Answer: C
Rationale: This response acknowledges the client's feelings and experiences, allowing for further exploration of the issues that brought him to the clinic, fostering therapeutic communication.
A client who is experiencing a severe level of anxiety reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?
- A. Help the client identify thoughts that may be triggers.
- B. Explore past behaviors that have provided relief.
- C. Attempt to distract to another focus or activity.
- D. Speak calmly to the client stating assurance of safety.
Correct Answer: D
Rationale: Speaking calmly and providing assurance of safety is the first step in managing severe anxiety, helping to stabilize the client.
A homeless female client who reports feeling sad and depressed tells the mental health nurse that in the past two days, the client has only had four hours of sleep. Which action is most important for the nurse to implement within the first 24 hours after treatment is initiated?
- A. Allow the client to rest and sleep.
- B. Begin planning for the client's discharge.
- C. Encourage verbalization of feelings.
- D. Ensure the client attends groups addressing coping skills for dealing with depression.
Correct Answer: A
Rationale: Allowing the client to rest and sleep is a priority, as sleep deprivation can exacerbate depression symptoms, addressing immediate physical needs.
A client is admitted to an inpatient psychiatric unit, and the antipsychotic medication clozapine is prescribed. Which intervention should the nurse include in this client's plan of care?
- A. Inform unlicensed assistive personnel (UAP) that the client will likely complain of a sore throat and fever.
- B. Place the client in protective isolation for the first two weeks of treatment with this medication.
- C. Offer this medication to the client with food to decrease the possibility of gastric upset.
- D. Report findings from the client's weekly white blood cell (WBC) counts to the healthcare provider.
Correct Answer: D
Rationale: Clozapine is associated with the risk of agranulocytosis, so regular monitoring of WBC counts and reporting findings to the healthcare provider is essential.