Nokea
In developing a nursing care plan for an adult with a mental health disorder, the nurse knows the goals that are set must be:
- A. Important to the client
- B. Evaluated on a weekly basis
- C. Achievable by client discharge
- D. Approved by the physician
Correct Answer: A
Rationale: Client-important goals boost engagement. Weekly evaluation is useful but not mandatory. Discharge-tied goals may not fit long-term needs. Physician approval is secondary to client-centered planning.
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A client is given the diagnosis of generalized anxiety disorder and is prescribed a benzodiazepine. The client should be instructed on which of the following?
- A. Monthly laboratory tests are needed to monitor drug level.
- B. Foods that contain tyramine should be avoided
- C. Benzodiazepines do not cause physical dependence.
- D. Benzodiazepines and alcohol can be dangerous
Correct Answer: D
Rationale: Lab tests aren’t routine for benzodiazepines. Tyramine avoidance applies to MAOIs, not benzodiazepines. Benzodiazepines can cause dependence, so that’s false. Combining benzodiazepines with alcohol increases CNS depression, posing risks like respiratory failure, making it critical to instruct the client on this danger.
An elderly client with severe cardiovascular disease is given the diagnosis of dementia. Which type of dementia does the client most likely have?
- A. Frontal
- B. Lewy body
- C. Alzheimer's
- D. Vascular dementia
Correct Answer: D
Rationale: Frontal (frontotemporal) dementia affects personality and behavior, not directly tied to cardiovascular issues. Lewy body dementia involves protein deposits and symptoms like hallucinations, not primarily cardiovascular-related. Alzheimer’s is common but linked to neurodegenerative changes, not specifically cardiovascular disease. Vascular dementia results from impaired blood flow to the brain, often due to cardiovascular conditions, making it the most likely here.
A nurse is caring for a client who was admitted with delirium five days ago. The client seeks permission from the nurse before performing ADLs. Which of the following actions should the nurse take?
- A. Quiz the client with orientation questions.
- B. Allow the client to function independently.
- C. Prepare the client for discharge.
- D. Determine the client's level of awareness.
Correct Answer: D
Rationale: Quizzing assesses but isn’t first. Independence is good but needs assessment first. Discharge is premature without evaluation. Determining awareness guides support, fitting delirium’s fluctuating nature.
A nurse is caring for a group of older adult clients. Which of the following client findings indicates delirium?
- A. A client expresses dislike of orange juice after reporting earlier that it was a favorite juice.
- B. A client wants to know what type of poison the nurse placed in her medication.
- C. A client requests extra blankets when the thermostat in the room indicates 80°F.
- D. A client asks when family members will be arriving after visiting 1 hr earlier.
Correct Answer: B
Rationale: Preference changes aren’t delirium-specific. Suspecting poison indicates delusional confusion, a delirium sign. Blankets in warmth suggest sensory issues, not delirium. Time confusion fits delirium, but poisoning suspicion is more acute.
A nurse is caring for a client who has depression and states that she is too tired to get out of bed or dress. Which of the following statements by the nurse is appropriate?
- A. If you do not get out of bed, you will not receive your meal.'
- B. You really need to follow the rules of the unit and get out of bed.'
- C. I will help you sit up and get your slippers on.'
- D. You should rest in bed until you feel able to take part in unit activities.'
Correct Answer: C
Rationale: Threatening to withhold meals is coercive. Enforcing rules dismisses the client’s fatigue. Offering help supports the client’s engagement without pressure, addressing depression’s lethargy. Encouraging rest may reinforce withdrawal, worsening depression.