Nokea
In observing a client who is pacing, agitated, and presenting aggressive gestures, with rapid speech pattern and belligerent affect, what is the immediate priority of care for the nurse?
- A. Provide safety for the client and other clients on the unit
- B. Provide the clients on the unit with a sense of comfort and safety
- C. Assist the staff in caring for the client in a controlled environment
- D. Offer the client a less stimulated area to calm down and gain control
Correct Answer: A
Rationale: In a situation where a client is displaying aggression and agitation, the immediate priority of care for the nurse is to ensure safety for the client and others on the unit. Providing a safe environment and implementing calming measures take precedence over other interventions. Option A is the correct choice as it addresses the crucial need for safety in a potentially volatile situation. Options B, C, and D, although important, do not address the primary concern of ensuring safety for all individuals involved.
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A male client with schizophrenia tells the nurse that the FBI is monitoring his phone calls. What is the nurse's best response?
- A. Let's talk about your feelings of being monitored.
- B. There is no evidence that the FBI is monitoring your calls.
- C. Why do you think the FBI is interested in your phone calls?
- D. I can assure you that your phone calls are not being monitored.
Correct Answer: A
Rationale: The correct response is to choose A: 'Let's talk about your feelings of being monitored.' This response shows empathy and encourages the client to express his feelings. Engaging the client in a discussion about his feelings can help address underlying fears without directly challenging the delusion. Choice B is incorrect because directly denying the delusion may lead to increased distrust or agitation in the client. Choice C may come across as confrontational, which can exacerbate the client's paranoia. Choice D offers a false sense of assurance and does not address the client's concerns effectively.
A newly admitted client describes her mission in life as one of saving her son by eliminating the 'provocative sluts' of the world. There are several attractive young women on the unit. What should the LPN/LVN do first?
- A. Ask the client for her definition of 'provocative sluts'
- B. Ask the young female clients on the unit to dress less provocatively
- C. Ask the client to discuss her concerns in the next group session
- D. Ask the client to inform the staff if she has negative thoughts about other clients
Correct Answer: D
Rationale: The correct action for the LPN/LVN to take first is to ask the client to inform the staff if she has negative thoughts about other clients. This approach is crucial as it helps in monitoring the client's thoughts and behaviors, potentially preventing any harmful actions towards others on the unit. Asking for the client's definition of 'provocative sluts' (Choice A) may not address the immediate concern of monitoring the client's harmful thoughts. Asking the young female clients to dress less provocatively (Choice B) is inappropriate and victim-blaming. Asking the client to discuss her concerns in the next group session (Choice C) may not be effective in addressing the potential harm the client's thoughts could pose to others on the unit.
The client with schizophrenia believes the news commentator is her lover and speaks to her. What is the best response for the nurse to make?
- A. What do you believe the news commentator said to you?
- B. Let's switch to a different news channel.
- C. Is the news commentator planning to harm you or others?
- D. The news commentator is not communicating with you.
Correct Answer: A
Rationale: The correct response is to ask the client what she believes the news commentator said, as it helps the nurse assess the client's perception and delve into her delusions without being confrontational. Choice B is not helpful in addressing the client's delusions. Choice C jumps to conclusions about potential harm without assessing the client's beliefs. Choice D is dismissive and does not address the client's reality.
A child is brought to the emergency room with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, 'I won't leave my son! Don't you touch him! You'll hurt my child!' What is the best interpretation of the mother's statements? The mother is
- A. regressing to an earlier behavior pattern.
- B. sublimating her anger.
- C. projecting her feelings onto the nurse.
- D. suppressing her fear.
Correct Answer: C
Rationale: The correct answer is (C) projecting her feelings onto the nurse. The mother's behavior suggests that she is attributing her own actions or feelings to the nurse, which is a form of projection. Option (A) regressing to an earlier behavior pattern is not the best fit in this context. Option (B) sublimating her anger is not applicable based on the given scenario. Option (D) suppressing her fear cannot be inferred from the provided information.
A female client on the psychiatric unit tells the nurse that she feels like ending her life because she can no longer deal with her depression. What is the nurse's priority intervention?
- A. Stay with the client and ensure her safety.
- B. Inform the client that she is safe in the hospital.
- C. Document the client's statements in her medical record.
- D. Encourage the client to join a group therapy session.
Correct Answer: A
Rationale: The correct answer is to stay with the client and ensure her safety. Ensuring the client's safety is the top priority when a client expresses suicidal ideation. Staying with the client can help prevent self-harm while further assessment and interventions are arranged. Choice B is incorrect because simply informing the client that she is safe in the hospital does not address the immediate need for safety. Choice C is incorrect as while documentation is important, it is not the priority when a client's safety is at risk. Choice D is also incorrect as encouraging the client to join a group therapy session is not appropriate when the client is in crisis and expressing suicidal thoughts.