Nokea
A client experiencing a manic episode is talking rapidly and jumping from one topic to another. Which term describes this symptom?
- A. Circumstantiality
- B. Flight of ideas
- C. Tangentiality
- D. Perseveration
Correct Answer: B
Rationale: In a manic episode, 'Flight of ideas' is characterized by rapid speech, where the individual moves quickly between topics without a clear connection. This symptom reflects the racing thoughts and impulsivity often seen in manic episodes. Circumstantiality refers to unnecessary detail and delay in getting to the point, tangentiality involves going off on a tangent or unrelated topics, and perseveration is the persistent repetition of a response or behavior. Therefore, 'Flight of ideas' best describes the symptom of rapidly changing topics during a manic episode.
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A client is experiencing alcohol withdrawal. Which intervention should be included in the plan of care?
- A. Administer benzodiazepines as prescribed.
- B. Monitor the client's vital signs every 4 hours.
- C. Provide a high-protein diet.
- D. Encourage the client to drink plenty of fluids.
Correct Answer: A
Rationale: Administering benzodiazepines as prescribed is a crucial intervention in managing alcohol withdrawal. Benzodiazepines help alleviate symptoms such as anxiety, agitation, and seizures commonly seen in alcohol withdrawal. Monitoring vital signs is important to assess the client's physiological stability, but addressing the withdrawal symptoms with benzodiazepines is a priority to prevent severe complications. Providing a high-protein diet and encouraging fluid intake are important for overall health but do not directly manage alcohol withdrawal symptoms.
Which client action is an example of the defense mechanism of reaction formation?
- A. A woman who feels unattractive constantly praises the looks of others.
- B. A man who feels insecure about his masculinity exaggerates his strength.
- C. A person who feels guilty about cheating accuses others of being unfaithful.
- D. A child who feels neglected tries to win approval from teachers.
Correct Answer: A
Rationale: The defense mechanism of reaction formation involves expressing the opposite of one's true feelings. In this case, the woman who feels unattractive praises the looks of others as a way to mask her own feelings of inadequacy. This behavior represents a form of overcompensation where the individual showcases an exaggerated opposite trait to conceal their true emotions. Choices B, C, and D do not align with reaction formation. Choice B describes compensation, where one overemphasizes a trait to make up for a perceived weakness. Choice C illustrates projection, where one attributes their feelings onto others. Choice D demonstrates a form of seeking attention or approval, which does not fit reaction formation.
When caring for a client with anorexia nervosa in a psychiatric unit, which intervention should the nurse implement to address the client's nutritional needs?
- A. Provide small, frequent meals throughout the day.
- B. Monitor the client's weight daily.
- C. Offer a liquid supplement if the client refuses solid food.
- D. Encourage the client to choose from a variety of food options.
Correct Answer: A
Rationale: Providing small, frequent meals throughout the day is a crucial intervention when caring for a client with anorexia nervosa. This approach helps in gradually increasing caloric intake and meeting the client's nutritional needs. Offering large meals can be overwhelming and may contribute to anxiety in these clients. By providing small, frequent meals, the nurse supports the client in establishing a healthier eating pattern and aids in the restoration of adequate nutrition levels. Monitoring the client's weight daily (Choice B) may exacerbate anxiety related to body image and weight, which are common concerns in anorexia nervosa. Offering a liquid supplement if the client refuses solid food (Choice C) may not address the underlying issues related to food aversion and may not provide the necessary nutrients in a balanced way. Encouraging the client to choose from a variety of food options (Choice D) may be overwhelming for someone with anorexia nervosa and could lead to increased anxiety around food choices.
A client is experiencing a moderate level of anxiety. Which is an example of an appropriate nursing intervention?
- A. Allow the client to pace in a safe environment.
- B. Encourage the client to discuss feelings.
- C. Help the client identify the cause of anxiety.
- D. Provide a distraction for the client.
Correct Answer: A
Rationale: Allowing the client to pace in a safe environment is an appropriate nursing intervention for managing moderate anxiety levels. Allowing pacing provides the client with a physical outlet for their anxiety and can help them release nervous energy without increasing distress. It promotes movement and can aid in reducing feelings of restlessness or agitation. Encouraging the client to discuss feelings (Choice B) is more suitable for addressing emotional aspects of anxiety rather than providing an immediate physical outlet. Helping the client identify the cause of anxiety (Choice C) may be more appropriate for long-term management but may not address the immediate need for physical release. Providing a distraction (Choice D) may not directly address the physical needs associated with moderate anxiety levels.
A client has been prescribed sertraline (Zoloft) and is receiving education from a healthcare provider. Which statement by the client indicates an accurate understanding of the medication?
- A. I should take this medication at the same time every day.
- B. It may take several weeks for this medication to be effective.
- C. I should take this medication on an empty stomach.
- D. I should avoid eating aged cheeses and processed meats.
Correct Answer: B
Rationale: The correct answer is B. Sertraline (Zoloft) may take several weeks to be effective, so it is important for the client to be informed about this timeframe. This medication does not need to be taken on an empty stomach, but it can be taken with or without food. Choice A is a good practice for many medications but not specifically related to sertraline (Zoloft). Choice D is not directly related to sertraline (Zoloft) but pertains to dietary restrictions when taking MAOIs due to potential interactions with tyramine.