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At the first meeting of a group of older adults at a daycare center for the elderly, the LPN/LVN asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, 'You tell me, you're the leader.' What is the best response for the nurse to make?
- A. Yes, I am the leader today. Would you like to be the leader tomorrow?
- B. Yes, I will be leading this group. What would you like to accomplish during this time?
- C. Yes, I have been assigned to be the leader of this group. I will be here for the next six weeks.
- D. Yes, I am the leader. You seem angry about not being the leader yourself.
Correct Answer: B
Rationale: The best response for the nurse is choice B: 'Yes, I will be leading this group. What would you like to accomplish during this time?' This response acknowledges the member's comment and encourages her to share her interests, promoting engagement and active participation in group activities. Choice A is not as inclusive and may not foster collaboration within the group. Choice C focuses more on the nurse's assignment rather than addressing the member's input. Choice D assumes emotions that were not expressed by the group member and does not encourage open communication.
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A young adult male with a history of substance abuse is admitted to the psychiatric unit for detoxification. He is agitated, sweating, and reports seeing bugs crawling on the walls. What is the priority nursing intervention?
- A. Reassure the client that the bugs are not real.
- B. Administer the prescribed benzodiazepine.
- C. Place the client in a quiet, dark room.
- D. Encourage the client to express his feelings.
Correct Answer: B
Rationale: The correct answer is to administer the prescribed benzodiazepine. This intervention helps manage the client's agitation and hallucinations, which are common symptoms during detoxification from substances. Reassuring the client that the bugs are not real (Choice A) may not be effective in addressing the underlying causes of the hallucinations. Placing the client in a quiet, dark room (Choice C) may help reduce sensory stimulation but does not directly address the client's symptoms. Encouraging the client to express his feelings (Choice D) is important for therapeutic communication but may not be the priority when the client is experiencing severe agitation and hallucinations.
A nurse is assessing a client with generalized anxiety disorder (GAD) who reports difficulty concentrating and feeling restless. What is the most appropriate nursing intervention?
- A. Encourage the client to avoid caffeine.
- B. Suggest the client take up a new hobby.
- C. Teach the client deep breathing exercises.
- D. Refer the client to group therapy.
Correct Answer: C
Rationale: Teaching deep breathing exercises is the most appropriate intervention for a client with generalized anxiety disorder (GAD) experiencing difficulty concentrating and restlessness. Deep breathing exercises are a proven technique to help manage anxiety symptoms, promote relaxation, and improve concentration. Encouraging the client to avoid caffeine (Choice A) may be beneficial, but it is not the most direct intervention for the reported symptoms. Suggesting the client take up a new hobby (Choice B) may be helpful for overall well-being but does not directly address the immediate symptoms. Referring the client to group therapy (Choice D) may be beneficial in the long term, but teaching deep breathing exercises is more immediate and can be easily implemented by the client in various settings.
An elderly client was prescribed Ativan 1 mg three times a day to help calm her anxiety after her husband's death. The next day the client calls her daughter asking when she is picking her up to go to the graveside. The client says she has been walking up and down the driveway for the past hour waiting for her daughter. Noting the client's agitation, hyperactivity, and insistence, the daughter calls the nurse to report her mother's behavior. What should the nurse suspect?
- A. The client is manic and may need a sleeping pill
- B. The client is experiencing a medication interaction and should go to the ED
- C. The client is experiencing a paradoxical reaction to the Ativan and should stop the new medication immediately
- D. The client is overcome by grief and probably needs an antidepressant
Correct Answer: C
Rationale: A paradoxical reaction to Ativan, where the drug causes opposite effects such as increased agitation and hyperactivity, should prompt immediate cessation of the medication. In this scenario, the client was prescribed Ativan to help calm her anxiety, but instead, she is displaying symptoms of increased agitation and hyperactivity, indicating a paradoxical reaction. Choice A is incorrect because the symptoms described do not align with mania. Choice B is incorrect as there is no mention of a medication interaction. Choice D is incorrect as the symptoms are more indicative of a paradoxical reaction rather than overwhelming grief.
A nurse is caring for a client who is experiencing withdrawal symptoms from opioid addiction. What is the priority nursing intervention?
- A. Monitor for signs of respiratory depression.
- B. Administer methadone as prescribed.
- C. Provide a calm and quiet environment.
- D. Encourage fluid intake to prevent dehydration.
Correct Answer: A
Rationale: The correct answer is A: Monitor for signs of respiratory depression. During opioid withdrawal, the priority is to monitor the client for respiratory depression as it can be life-threatening. Respiratory depression is a serious concern during opioid withdrawal, and prompt recognition and intervention are crucial. Administering methadone as prescribed (Choice B) may be part of the treatment plan but is not the priority in this situation. Providing a calm and quiet environment (Choice C) and encouraging fluid intake to prevent dehydration (Choice D) are important aspects of care but do not take precedence over monitoring for respiratory depression.
A female client with depression attends a group and states that she sometimes misses her medication appointments because she feels very anxious about riding the bus. Which statement is the nurse's best response?
- A. Can your case manager take you to your appointments?
- B. Take your medication for anxiety before you ride the bus.
- C. Let's talk about what happens when you feel very anxious.
- D. What are some ways that you can cope with your anxiety?
Correct Answer: D
Rationale: Encouraging the client to discuss coping mechanisms for anxiety is a supportive approach that empowers the client to manage their symptoms. Choice A may not address the client's self-management and coping skills. Choice B suggests using anxiety medication before riding the bus, which may not be the most appropriate solution. Choice C acknowledges the anxiety but does not actively involve the client in finding solutions, unlike Choice D which promotes client empowerment and self-efficacy.