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During an annual physical at the corporate clinic, a male employee expresses to the RN that his high-stress job is causing trouble in his personal life. He mentions getting so angry while driving to and from work that he has considered 'getting even' with other drivers. How should the RN respond?
- A. "Anger is contagious and could lead to major confrontations."
- B. "Try not to let your anger cause you to act impulsively."
- C. "Expressing your anger to a stranger could lead to an unsafe situation."
- D. "It seems like there are many situations that make you feel angry."
Correct Answer: B
Rationale: The correct response for the RN is to advise the employee not to act impulsively when feeling angry. This approach helps the individual learn to manage anger in a constructive manner, reducing the likelihood of potential conflicts. Choice A is incorrect because while acknowledging that anger can escalate into confrontations is valid, it does not provide immediate guidance on managing the anger. Choice C focuses on the dangers of expressing anger to strangers but does not address the core issue of managing anger. Choice D simply acknowledges the employee's feelings without providing guidance on how to address the situation effectively.
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A female client with obsessive-compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving and reports her findings to the RN at bedtime. What action should the nurse implement?
- A. Explain to the client that her behavior invades the rights of the nursing staff.
- B. Ask the client to explain why she is keeping a detailed record of her nursing care.
- C. Teach the client strategies to control her obsessive-compulsive behavior.
- D. Encourage the client to express her feelings regarding the upcoming procedure.
Correct Answer: B
Rationale: Asking the client to explain why she is keeping a detailed record of her nursing care is the most appropriate action for the nurse to take in this situation. Understanding the client's motivations for keeping detailed records can provide insight into her obsessive-compulsive behaviors and help manage them effectively. Choice A is incorrect because it may come across as confrontational and not address the underlying reasons for the behavior. Choice C is incorrect as teaching strategies to control behavior should be done after understanding the client's motives. Choice D is incorrect as it does not directly address the behavior of keeping detailed records.
While working with a male client at a community mental health center, the client reports hearing voices that tell him to get a knife from the kitchen and hurt himself. What intervention is most important for the RN to implement?
- A. Prevent the client from going into the kitchen until the hallucination has subsided.
- B. Report the behavior to the client's case workers to notify the family.
- C. Assign a UAP to stay with the client continuously.
- D. Document the behavior in the client's record and inform the HCP.
Correct Answer: A
Rationale: Preventing the client's access to potential means of self-harm is the immediate priority to ensure his safety. While it is crucial to report concerning behaviors to the client's case workers for further support, addressing the immediate risk of harm takes precedence. Assigning a UAP to stay with the client is important for continuous monitoring but is secondary to ensuring immediate safety. Documenting the behavior in the client's record and notifying the healthcare provider are essential steps in the care process; however, they should follow actions taken to ensure the client's immediate safety.
The nurse on the day shift receives report about a client with depression who was found on the floor in the morning. What intervention is best for the nurse to implement?
- A. Assist the client to get out of bed and involved in an activity.
- B. Monitor the client's appetite and sleep patterns.
- C. Assess the client's feelings regarding the hospital stay.
- D. Explain that staff will check on the client every 30 minutes.
Correct Answer: A
Rationale: Assisting the client to engage in activities is the best intervention as it can help improve mood and prevent further decline in function. Option B, monitoring appetite and sleep patterns, is important but not the most immediate intervention needed in this situation. Option C, assessing feelings about the hospital stay, is also important but addressing the client's physical safety and well-being should take precedence. Option D, explaining the frequency of staff checks, is not as effective in addressing the client's immediate needs for engagement and support.
A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN?
- A. Is attempting the physically restrain the patient.
- B. Remains at a distance of 4 feet from the client.
- C. Tells the client to go to the quiet area of the unit.
- D. Is using a loud voice to talk to the client.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A female client engages in repeated checks of door and window locks, a behavior that prevents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take?
- A. Ask the client why she checks the locks.
- B. Discuss checking the time frequently.
- C. Determine the type and size of the locks.
- D. Plan a list of activities to be carried out daily.
Correct Answer: D
Rationale: Planning a list of daily activities can help the client manage her time better and reduce the impact of her compulsive behaviors. Option A is incorrect because simply asking why the client checks the locks may not address the underlying issue effectively. Option B is not relevant to the compulsive behavior of checking locks. Option C does not directly address the client's compulsive behavior but focuses on the physical attributes of the locks.