Nokea
During a manic episode, what is the most appropriate nursing intervention for a client with bipolar disorder?
- A. Allow the client to engage in any activities they choose.
- B. Provide a quiet and structured environment.
- C. Encourage the client to participate in group activities.
- D. Allow the client to take short naps during the day.
Correct Answer: B
Rationale: During a manic episode, individuals with bipolar disorder often experience excessive energy and impulsivity. Providing a quiet and structured environment is crucial to help manage these symptoms. This intervention promotes stability, reduces overstimulation, and supports the client in regaining control over their behaviors. Choices A and C may exacerbate impulsivity and overstimulation, while choice D does not address the need for environmental structure and may not be effective in managing manic symptoms.
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A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin decanoate) is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation in the Bahamas and will return in 18 days. Which statement by the client indicates a need for health teaching?
- A. "When I return from my tropical island vacation, I will go to the clinic to get my Prolixin injection."
- B. "While I am on vacation and when I return, I will not consume any alcohol-containing food or beverages."
- C. "I will inform the healthcare provider if I develop a sore throat or flu-like symptoms."
- D. "I will maintain my daily intake of benztropine mesylate (Cogentin)."
Correct Answer: A
Rationale: Photosensitivity is a side effect of Prolixin, and a vacation in the Bahamas (with its tropical island climate) increases the client's risk of experiencing this side effect. Therefore, the client should be advised to avoid direct sun exposure. Choice A indicates a need for health teaching as the client plans to return from vacation in 18 days, which is earlier than the scheduled dose of Prolixin at 20 days after discharge. Choices B, C, and D demonstrate accurate knowledge. Choice B is important because alcohol can interact with Prolixin. Choice C is relevant as it mentions signs of agranulocytosis, a potential side effect of Prolixin. Choice D is correct as benztropine mesylate is used to prevent extrapyramidal symptoms associated with Prolixin.
A client with obsessive-compulsive disorder (OCD) spends hours each day washing their hands. Which nursing intervention is most appropriate initially?
- A. Allow the client to continue the behavior to reduce anxiety.
- B. Set strict limits on the time allowed for handwashing.
- C. Distract the client with other activities.
- D. Encourage the client to participate in a support group.
Correct Answer: A
Rationale: Initially, it is most appropriate to allow the client to continue the behavior to reduce anxiety (A). For clients with OCD, abruptly stopping compulsive behaviors can lead to increased anxiety and distress. Setting strict limits (B) may exacerbate anxiety at first. Distraction with other activities (C) may not address the underlying issue effectively. While support groups (D) can be beneficial, they are typically introduced after establishing trust and gradually working on reducing compulsive behaviors.
The LPN/LVN is caring for a client who was recently diagnosed with a mental illness. The client asks, 'Will I be able to live a normal life?' What is the best response for the nurse to provide?
- A. Yes, you will be able to live a normal life.
- B. Many people with mental illness lead full and productive lives.
- C. It will depend on your treatment and the choices you make.
- D. There is no normal; everyone is unique in their own way.
Correct Answer: C
Rationale: The best response for the nurse is to provide the client with hope while acknowledging the importance of their treatment and choices. Choice C addresses the client's concern by highlighting the impact of their treatment and personal choices on their future. It encourages personal responsibility and active participation in their recovery. Choices A and B may sound reassuring, but they do not empower the client to take an active role in their well-being. Choice D, while promoting individuality, does not directly address the client's question about living a normal life after a mental illness diagnosis.
When caring for a client with borderline personality disorder in a psychiatric unit, what is the most therapeutic nursing intervention?
- A. Set clear and consistent boundaries for the client.
- B. Allow the client to vent their feelings without interruption.
- C. Encourage the client to participate in group therapy.
- D. Provide the client with frequent reassurance and support.
Correct Answer: A
Rationale: Setting clear and consistent boundaries is the most therapeutic nursing intervention when caring for a client with borderline personality disorder. This approach provides structure, promotes predictability, and helps prevent manipulative behaviors. By establishing boundaries, the nurse can maintain a safe therapeutic relationship with the client. Allowing the client to vent their feelings without interruption (Choice B) may not always be beneficial, as it could reinforce maladaptive behaviors. Encouraging participation in group therapy (Choice C) can be helpful but setting boundaries is more critical for individualized care. Providing the client with frequent reassurance and support (Choice D) may not address the underlying issues and can contribute to dependency rather than fostering independence and coping skills.
An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, 'Where should I stand for the parade?' Which response is best for the nurse to provide?
- A. "You can stand wherever you'd like as long as you stay safe from those in the parade."
- B. "You seem confused because of all the activity in the hall. There is no parade."
- C. "Let's go back to the activity room and see what is going on in there."
- D. "Remember, this is a nursing home, and I am here to help you."
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.