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In the emergency department, the nurse assesses a client who is aggressive and experiencing auditory hallucinations. The client states,"The CIA is plotting to kill me." To which mental health setting would the nurse expect this client to be admitted?
- A. Long-term, inpatient facility.
- B. Day treatment.
- C. Short-term, inpatient, locked unit.
- D. Psychiatric case management.
Correct Answer: C
Rationale: The correct answer is C: Short-term, inpatient, locked unit. This setting is appropriate because the client is exhibiting acute symptoms of aggression and auditory hallucinations, indicating a need for close monitoring and safety precautions in a secure environment. Long-term inpatient facility (choice A) is not suitable for acute episodes. Day treatment (choice B) may not provide the level of supervision needed. Psychiatric case management (choice D) focuses on community-based care, not acute inpatient care. Therefore, choice C is the most appropriate for managing the client's current symptoms.
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A staff nurse on a psychiatric unit knows that patients often have trouble sleeping because of their psychiatric conditions. Which of the following would reflect a psychiatric nursing intervention to appropriately address this problem?
- A. Limiting amounts of evening snacks and beverages
- B. Involving patients in a volleyball game immediately before bedtime
- C. Enforcing the rule that all patients be in bed with lights out by 10:30 PM
- D. Encouraging patients to take short naps in the afternoons
Correct Answer: A
Rationale: Correct Answer: A: Limiting amounts of evening snacks and beverages
Rationale:
1. Limiting evening snacks and beverages can help regulate patients' sleep patterns by reducing stimulants that may interfere with sleep.
2. Nutrition plays a role in sleep quality, and avoiding heavy meals close to bedtime can promote better sleep.
3. This intervention addresses a common issue in psychiatric patients without imposing strict rules or physical activity.
4. It focuses on a holistic approach to improving sleep quality by considering dietary factors.
Summary:
B: Involving patients in a volleyball game immediately before bedtime - This choice is incorrect as vigorous physical activity before bedtime can be stimulating and may disrupt sleep.
C: Enforcing the rule that all patients be in bed with lights out by 10:30 PM - This choice is incorrect as it is too rigid and may not address the underlying causes of sleep disturbances.
D: Encouraging patients to take short naps in the afternoons - This choice is incorrect as daytime
Taylor, a psychiatric registered nurse, orients Regina, a patient with anorexia nervosa, to the room where she will be assigned during her stay. After getting Regina settled, the nurse informs Regina:
- A. I need to go through the belongings you have brought with you.
- B. You can use the scale in the back room when you need to.
- C. You will be eating five times a day here.
- D. The daily structure is based around your desire to eat.
Correct Answer: A
Rationale: The correct answer is A because as a psychiatric nurse, it is important to ensure the safety of the patient, especially those with anorexia nervosa who may have harmful items in their belongings. Going through the patient's belongings allows the nurse to assess and remove any potential risks. This action aligns with the duty of care and ensures the patient's well-being.
Choice B is incorrect because using a scale can trigger anxiety and reinforce unhealthy behaviors related to weight monitoring in patients with anorexia nervosa. Choice C is incorrect as stating a specific number of meals may not be suitable for every individual and could create unnecessary pressure on the patient. Choice D is incorrect because the structure of care should be based on evidence-based practices and clinical guidelines, not solely on the patient’s desire to eat.
A nurse documents: "Patient is mute despite repeated efforts to elicit speech. Makes no eye contact. Inattentive to staff. Gazes off to the side or looks upward rather than at speaker." Which nursing diagnosis should be considered?
- A. Defensive coping
- B. Decisional conflict
- C. Risk for other-directed violence
- D. Impaired verbal communication
Correct Answer: D
Rationale: The correct answer is D: Impaired verbal communication. The patient's inability to speak, make eye contact, and focus on the speaker indicates a communication issue. Impaired verbal communication relates to difficulty expressing thoughts, feelings, or needs. The patient's behavior aligns with this diagnosis as they are mute, inattentive, and not making eye contact. Defensive coping (A) involves protecting oneself from emotional pain. Decisional conflict (B) pertains to uncertainty about choices. Risk for other-directed violence (C) involves potential harm to others, which is not evident in the scenario. Thus, D is the most appropriate nursing diagnosis.
The nurse has instructed a client with panic disorder about how to use the technique of positive self-talk. The nurse determines that the client has understood the instructions when the client verbalizes which statement to use during an impending panic attack?
- A. I am feeling very nervous right now.
- B. I can handle this anxiety; it will be over shortly.
- C. I am taking medication to eliminate these symptoms.
- D. Relax your muscles, relax your muscles.
Correct Answer: B
Rationale: The correct answer is B: "I can handle this anxiety; it will be over shortly." This statement reflects positive self-talk by acknowledging the anxiety but also affirming the client's ability to cope and that the situation is temporary. This empowers the client to manage the panic attack effectively.
Incorrect Choices:
A: "I am feeling very nervous right now." This choice focuses only on acknowledging the feeling without providing a positive coping strategy.
C: "I am taking medication to eliminate these symptoms." This choice relies solely on medication and does not address the client's ability to cope with the panic attack.
D: "Relax your muscles, relax your muscles." This choice provides a relaxation technique but lacks the empowering and affirming aspect of positive self-talk.
Johnny is twelve-year-old boy who has had an increase in aggressive behaviors, picking fights with other students at his school. Johnny's mother calls his doctor's office to ask if there is medication to help decrease these behaviors. After gathering more information about the recent increase in Johnny's outbursts, what is the best response from the nurse?
- A. Allow more freedom at home as that may be adding to his outbursts.'
- B. Medication may not be indicated right away; there are other options.'
- C. Tell Johnny that his behavior is unacceptable.'
- D. Allow Johnny to skip school if he is having a difficult time being there.'
Correct Answer: B
Rationale: The correct answer is B: Medication may not be indicated right away; there are other options.
Rationale:
1. Medication should not be the first line of intervention for behavior issues in children.
2. It is important to explore other options such as therapy, counseling, behavior modification techniques.
3. Understanding the root cause of Johnny's behavior is crucial before considering medication.
4. Rushing into medication without exploring other avenues may not address the underlying issues.
Summary:
A: Allowing more freedom at home could potentially worsen Johnny's behavior by reinforcing the negative actions.
C: Telling Johnny his behavior is unacceptable without addressing the underlying cause may not effectively reduce his aggression.
D: Allowing Johnny to skip school is not a solution; addressing the behavior and providing appropriate support is essential.