Nokea
Nurses' Notes
• Diagnosis: depression and post-traumatic stress disorder Diphenhydramine 12.5 mg PO every night at sleep (HS) • Buspirone hydrochloride 7.5 mg PO twice a day
During the conversation with the client, the nurse documents a statement by the client about wishing she had died in the crash.
During the conversation with the client, the nurse documents a statement by the client about wishing she had died in the crash. The statement by the client represents and should be followed up with an
- A. suicidal ideation, assessment of risk factors for suicide
Correct Answer: A
Rationale: The client's statement reflects suicidal ideation, requiring immediate assessment of suicide risk factors (e.g., history, stressors, support systems) to determine appropriate interventions, ranging from monitoring to psychiatric evaluation.
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The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in depth with the client based on this screening tool?
- A. Efforts to cut down, annoyance with questions, guilt, drinking as an 'Eye-opener'
- B. Consumption, liver enzyme, gastrointestinal complaints and bleeding
- C. Cancer screening results, anger, gastritis, daily alcohol intake
- D. Minimizes drinking, frequently misses family events, guilt about drinking, amount of daily intake
Correct Answer: A
Rationale: The CAGE questionnaire focuses on four key aspects: efforts to Cut down, Annoyance with questions, Guilt about drinking, and Eye-opener use. Exploring these provides insight into potential alcohol problems. Other options include relevant aspects but are not specific to the CAGE questionnaire.
The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessment?
- A. The snakes on the wall are going to eat me
- B. The nurse at night is trying to poison me with pills
- C. The voices are telling me to kill the next person I see
- D. The fire is burning my skin away right now
- E. None
- F. None
Correct Answer: B
Rationale: The nurse at night is trying to poison me with pills' confirms a delusion, specifically a paranoid delusion, as it reflects a fixed, false belief not based in reality. The other options describe hallucinations: visual ('snakes'), auditory ('voices'), and tactile ('fire'). Delusions involve false beliefs, while hallucinations involve false sensory perceptions.
A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?
- A. Concentrate on and ventilate emotions when distressed
- B. Relax and reduce the amount of effort to solve the problem
- C. Shift attention from self to the needs and requests of others
- D. Focus on small achievable tasks, not taxing problems
Correct Answer: D
Rationale: Focusing on small achievable tasks promotes a sense of accomplishment, counteracting helplessness and supporting behavioral activation for depression. Ventilating emotions may not address avoidance. Reducing effort may worsen helplessness. Shifting attention to others does not directly address depressive symptoms.
A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?
- A. Ineffective sexual patterns
- B. Disturbed sensory perception
- C. Compromised family coping
- D. Impaired environmental interpretation
Correct Answer: B
Rationale: The client's delusions (e.g., being married to a movie star, brother's intentions) indicate disturbed sensory perception, suggestive of psychosis, which is the priority. Ineffective sexual patterns are not directly indicated. Family coping may be secondary. Impaired environmental interpretation is too broad.
A nurse is caring for a client:
The client has returned to work at an accounting firm and has started going to a grief support group. She reports she is seeking care from a healthcare professional because her father is worried about her. The client says she only gets 2 to 3 hours of sleep due to nightmares about the crash. She informs that exercising right after work helps her get better sleep and to relax. She feels that she is "jumpy" after the accident, especially when she is in the car. She also stated, "I feel so sad that I can't seem to feel anything at all." In addition to her father, the client has a large family and friend support system. She denies alcohol or drug use.
Click to highlight the areas that the nurse should react to immediately. The client has returned to work at an accounting firm and has started going to a grief support group. She reports she is seeking care from a healthcare provider because her father is worried about her. The client says she only gets 2 to 3 hours of sleep due to nightmares about the crash. She informs that exercising right after work helps her get better sleep and to relax. She feels that she is 'jumpy' after the accident, especially when she is in the car. She also stated, 'I feel so sad that I can't seem to feel anything at all.' In addition to her father, the client has a large family and friend support system. She denies alcohol or drug use.
- A. she only gets 2 to 3 hours of sleep
- B. She feels that she is 'jumpy' after the accident
- C. I feel so sad that I can't seem to feel anything at all
Correct Answer: A,B,C
Rationale: Sleep disturbances, heightened startle response ('jumpy'), and sadness/numbness indicate possible acute stress or PTSD, requiring immediate intervention like creating a safe environment and mental health referral. These symptoms suggest significant distress post-trauma.