Nokea
A nurse is caring for a client who has been diagnosed with schizoaffective disorder. The client states, 'I am the president of the United States.' Which of the following responses should the nurse make?
- A. You are not the president. You are a client in the hospital.
- B. Tell me more about being the president.
- C. Why do you think you are the president?
- D. Let's talk about something else.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client has a history of excessive drinking, which has led to multiple arrests for driving under the influence (DUI). The client states, 'I work hard to provide for my family. I don't see why I can't drink to relax.' The nurse recognizes the use of which defense mechanism?
- A. Projection
- B. Rationalization
- C. Regression
- D. Sublimation
Correct Answer: B
Rationale: The correct answer is Rationalization. The client is using rationalization as a defense mechanism by justifying their excessive drinking as a way to relax due to working hard to provide for their family. Rationalization involves creating logical excuses to justify unacceptable feelings or behaviors. Projection involves attributing one's unacceptable feelings or thoughts to others. Regression is reverting to an earlier stage of development in the face of unacceptable thoughts or impulses. Sublimation is the channeling of unacceptable impulses into socially acceptable activities.
During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, 'I'm here for my heart, not my head problems.' What is the nurse's best response?
- A. It's just a routine part of our assessment. All clients are asked these same questions.
- B. Why are you concerned about these types of questions?
- C. Psychological factors, like excessive stress, have been found to affect medical conditions.
- D. We can skip these questions, if you like. It isn't imperative that we complete this section.
Correct Answer: C
Rationale: The nurse should educate the client about the impact of psychological factors, such as excessive stress, on medical conditions. Understanding this connection is crucial in providing holistic care. It is essential to address both physiological and psychosocial aspects during the assessment to obtain a comprehensive understanding of the client's health status and needs. Choice A is incorrect as it doesn't address the importance of psychosocial aspects on medical conditions. Choice B is not the best response as it does not provide valuable information about the connection between psychological factors and medical conditions. Choice D is incorrect because skipping these questions could lead to missing crucial information that may impact the client's overall well-being and treatment plan.
A client has been prescribed lithium for the treatment of bipolar disorder. Which of the following instructions should the nurse include?
- A. Avoid driving until you know how the medication affects you.
- B. Take the medication with food to prevent stomach upset.
- C. You may experience mild nausea when initiating the medication.
- D. Do not double the next dose if you miss one.
Correct Answer: A
Rationale: The correct instruction for the nurse to provide is to advise the client to avoid driving until they know how the medication affects them. Lithium can lead to side effects like dizziness and drowsiness, which could impair one's ability to drive safely. Choice B is incorrect because lithium is usually taken on an empty stomach. Choice C may be true but is not as critical as the potential side effects affecting driving. Choice D is important but not as immediate as ensuring the client's safety while driving.
Which of the following interventions are appropriate for a client experiencing a panic attack? Select one that does not apply.
- A. Stay with the client and remain calm
- B. Encourage deep breathing
- C. Move the client to a quiet environment
- D. Mindfulness meditation
Correct Answer: D
Rationale: During a panic attack, it is crucial to provide immediate support to the client. Appropriate interventions include staying with the client and remaining calm, encouraging deep breathing, and moving the client to a quiet environment. However, mindfulness meditation, which involves focusing on the present moment and may require a certain level of concentration, may not be feasible or effective during an acute panic attack. The priority is to help the client feel safe and supported, which the other interventions address more directly. Mindfulness meditation might not be suitable during a panic attack due to the heightened state of anxiety and the need for immediate calming techniques.
A client with schizophrenia is prescribed an antipsychotic medication. Which of the following side effects should the nurse monitor for? Select one that does not apply.
- A. Tardive dyskinesia
- B. Neuroleptic malignant syndrome
- C. Mindfulness meditation
- D. Hyperglycemia
Correct Answer: C
Rationale: The correct answer is C, 'Mindfulness meditation.' Side effects of antipsychotic medications include tardive dyskinesia, neuroleptic malignant syndrome, orthostatic hypotension, and hyperglycemia. Mindfulness meditation is not a side effect of antipsychotic medications. Choices A, B, and D are all potential side effects of antipsychotic medications. Tardive dyskinesia is a movement disorder characterized by repetitive, involuntary movements. Neuroleptic malignant syndrome is a rare but life-threatening reaction to antipsychotic medication. Hyperglycemia can occur as a side effect of some antipsychotic medications, particularly the second-generation ones.