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During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process?
- A. Assist the client in developing alternative coping skills.
- B. Remain calm and use a matter of fact approach.
- C. Ask the client why she is so anxious
- D. Administer a PRN sedative to help relieve her anxiety.
Correct Answer: B
Rationale: The correct answer is B: Remain calm and use a matter-of-fact approach. This approach is essential to provide a sense of safety and security for the client experiencing extreme anxiety. By remaining calm, the nurse can model a calming presence and help the client feel more at ease. Using a matter-of-fact approach can help normalize the situation and reassure the client that her feelings are valid but manageable.
A: Assisting the client in developing coping skills may be beneficial in the long term, but in this acute situation, the immediate focus should be on providing immediate support.
C: Asking the client why she is anxious may not be helpful as it can potentially increase her anxiety or lead to a delusional explanation.
D: Administering a sedative should not be the first intervention as it does not address the underlying cause of the anxiety and may mask important information that could help in providing appropriate care.
In summary, the most important intervention is remaining calm and using a matter-of-fact
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A female patient diagnosed with schizophrenia has been prescribed a first-generation antipsychotic medication. What information should the nurse provide to the patient regarding her signs and symptoms?
- A. Her memory problems will likely decrease.
- B. Depressive episodes should be less severe.
- C. She will probably enjoy social interactions more.
- D. She should experience a reduction in hallucinations.
Correct Answer: D
Rationale: The correct answer is D: She should experience a reduction in hallucinations. First-generation antipsychotic medications are primarily used to target positive symptoms of schizophrenia, such as hallucinations. These medications work by blocking dopamine receptors in the brain, which can help reduce hallucinations. Providing this information to the patient is crucial for managing expectations and understanding the potential benefits of the prescribed medication.
Choices A, B, and C are incorrect because first-generation antipsychotics do not specifically address memory problems, depressive episodes, or social interactions. While some side effects of the medication may impact these areas, the primary focus is on reducing hallucinations and other positive symptoms of schizophrenia. It is important for the nurse to provide accurate information to the patient to ensure effective treatment and management of their condition.
An antidepressant medication is prescribed for a client who reports sleeping only 4 hours in the past 2 days and weight loss of 9 lbs within the last month. Which client goal is most important to achieve within the first three days of treatment?
- A. Meet scheduled appointment with dietitian.
- B. Sleep at least 6 hours a night.
- C. Understands the purpose of the medication regimen.
- D. Describes the reasons for hospitalization.
Correct Answer: B
Rationale: The correct answer is B: Sleep at least 6 hours a night. Adequate sleep is crucial in the management of depression as it can improve mood, cognition, and overall functioning. Lack of sleep can exacerbate depressive symptoms. Addressing sleep disturbance early can lead to an improvement in the client's overall well-being. Meeting with a dietitian (choice A) may be important for addressing weight loss but is not as urgent as improving sleep. Understanding the purpose of the medication regimen (choice C) is important for long-term treatment adherence but may not be the priority within the first three days. Describing the reasons for hospitalization (choice D) is not directly related to the immediate treatment goal of addressing sleep disturbance.
Carolina is surprised when her patient does not show for a regularly scheduled appointment. When contacted, the patient states, 'I don’t need to come see you anymore. I have found a therapy app on my phone that I love.' How should Carolina respond to this news?
- A. That sounds exciting, would you be willing to visit and show me the app?
- B. At this time, there is no real evidence that the app can replace our therapy.
- C. I am not sure that is a good idea right now, we are so close to progress.
- D. Why would you think that is a better option than meeting with me?
Correct Answer: A
Rationale: Rationale for Choice A: Carolina should respond positively to the patient's enthusiasm about the therapy app to maintain rapport. By asking the patient to show the app, Carolina displays genuine interest and open-mindedness, fostering a collaborative discussion. This approach allows Carolina to understand the patient's perspective and potentially integrate the app into the therapy if suitable. It also shows respect for the patient's autonomy in seeking alternative support.
Summary of other choices:
B: This response is dismissive and does not acknowledge the patient's preferences, potentially damaging the therapeutic relationship.
C: This response may come off as controlling or resistant, risking alienating the patient and hindering progress.
D: This response is confrontational and may make the patient defensive, leading to communication breakdown rather than exploration of alternatives.
A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement?
- A. Isolate the client from the other clients.
- B. Administer PRN sedative.
- C. Avoid recognizing the behavior.
- D. Escort the client to his room.
Correct Answer: C
Rationale: The correct answer is C: Avoid recognizing the behavior. Echolalia is the repetition of words or phrases spoken by others, common in schizophrenia. By not reinforcing or acknowledging the behavior, the client may eventually stop. Isolating the client (Choice A) may lead to feelings of rejection. Administering a sedative (Choice B) may not address the underlying behavior. Escorting the client to his room (Choice D) does not address the echolalia directly.
During an admission assessment and interview, which channels of information communication should the nurse be monitoring? Select all that apply.
- A. Auditory
- B. Visual
- C. Written
- D. Tactile
Correct Answer: A
Rationale: The correct answer is A: Auditory. During an admission assessment and interview, monitoring auditory communication channels is crucial for gathering information through spoken words, tone, and non-verbal cues like sighs or hesitations. This helps the nurse assess the patient's mental state, emotions, and communication effectiveness. Visual (B), written (C), and tactile (D) channels are not typically monitored during a standard interview, as they may not provide relevant information for the assessment process. Visual cues like body language can be important but are not as essential as auditory cues in this context. Written communication is not typically used in a face-to-face interview, and tactile communication is usually unnecessary unless specific procedures are being performed.