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A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity?
- A. The client runs 4 miles outdoors every afternoon.
- B. The client drinks 2 liters of liquids daily.
- C. The client eats 2-3 grams of sodium-containing foods daily.
- D. The client eats foods high in tyramine.
Correct Answer: A
Rationale: The correct answer is A. Running 4 miles daily causes excessive sweating, leading to dehydration and potential lithium toxicity. Lithium is excreted through the kidneys and dehydration can decrease kidney function, causing lithium levels to rise. Choices B and C are actually helpful as adequate hydration and normal sodium intake reduce the risk of lithium toxicity. Choice D is irrelevant as tyramine is not linked to lithium toxicity.
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A nurse is caring for a client who has a new diagnosis of human immunodeficiency virus (HIV). He states, "I don't care what the doctors say, there is no way I can have HIV, and I don't need treatment for something I don't have." The nurse identifies that the client is experiencing which of the following types of crisis?
- A. Adventitious
- B. Internal
- C. Maturational
- D. Situational
Correct Answer: D
Rationale: The correct answer is D: Situational crisis. The client's denial of the HIV diagnosis and refusal of treatment indicate an acute crisis triggered by a specific event or situation - the new HIV diagnosis. In a situational crisis, individuals struggle to cope with a sudden and unexpected event, leading to cognitive dissonance and emotional distress. The client's disbelief and avoidance of the reality of the diagnosis demonstrate a maladaptive response to the crisis. Adventitious crisis (A) refers to events like natural disasters, which are not applicable here. Internal crisis (B) involves inner conflicts, not evident in this scenario. Maturational crisis (C) arises from developmental life stages, which is not the case here.
Where should a nurse assign a client experiencing manic behavior?
- A. Semi-private room across from the day room
- B. Private room in a quiet location
- C. Semi-private room across from the snack area
- D. Shared room near the nursing station
Correct Answer: B
Rationale: The correct answer is B: Private room in a quiet location. This choice is appropriate because a client experiencing manic behavior requires a calm and quiet environment to minimize stimulation and help reduce agitation. Placing the client in a private room can provide the necessary space for the client to calm down and prevent potential triggers for further manic episodes.
Other choices are incorrect:
A: A semi-private room across from the day room may expose the client to increased noise and activity, which can exacerbate manic behavior.
C: A semi-private room across from the snack area may lead to distractions and potential interactions that can escalate the manic behavior.
D: A shared room near the nursing station may not offer the privacy and quiet environment needed for a client experiencing manic behavior to stabilize.
A nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?
- A. Disclose some personal information to the client to demonstrate approachability.
- B. Wait for the client to initiate interaction.
- C. Approach the client frequently throughout the day for brief interactions.
- D. Adopt a neutral attitude when providing care.
Correct Answer: D
Rationale: The correct answer is D: Adopt a neutral attitude when providing care. This approach is appropriate because it helps to build trust with a suspicious client by not evoking any feelings of threat or manipulation. By maintaining a neutral attitude, the nurse can establish a safe and non-threatening environment for the client to gradually open up and develop a therapeutic relationship.
Other choices are incorrect because:
A: Disclosing personal information may blur professional boundaries and make the client more suspicious.
B: Waiting for the client to initiate interaction may prolong the time it takes to establish a connection.
C: Approaching the client frequently may overwhelm the client and reinforce their suspicions.
E, F, G: These options are not provided in the question, so they cannot be evaluated.
A nurse is caring for a client who has schizophrenia and is experiencing a hallucination. Which of the following actions should the nurse take?
- A. Act as if the hallucination is real.
- B. Instruct the client to argue with the voices that are a part of the hallucination.
- C. Ask the client direct questions about the hallucination.
- D. Tell the client that the hallucination is not a part of reality.
Correct Answer: C
Rationale: The correct answer is C - Ask the client direct questions about the hallucination. This approach helps the nurse understand the client's experience without validating or denying the hallucination. It shows empathy and promotes trust. Choice A would validate the hallucination, worsening the client's condition. Choice B could escalate the situation by encouraging confrontation with the voices. Choice D may cause the client to feel dismissed or judged. Asking direct questions (C) allows the nurse to gather information, assess the client's safety, and provide appropriate care.
A nurse is providing discharge teaching for a client who has multiple medication prescriptions and must take the medications at specific intervals when at home. Which of the following instructions should the nurse include in the teaching?
- A. "You really shouldn't change the schedule we established here in the facility."
- B. "Let's work together to devise a time schedule that is convenient for you on a daily basis."
- C. "I'll have to talk to your provider about switching to an alternative schedule."
- D. "It doesn't really matter what time you take your medications as long as you don't skip any doses."
Correct Answer: B
Rationale: The correct answer is B. By working together to devise a time schedule convenient for the client, the nurse ensures medication adherence. This approach promotes patient autonomy and empowerment, increasing the likelihood of compliance. Choice A is incorrect as it disregards the client's needs. Choice C involves unnecessary steps and may delay important changes. Choice D is incorrect as adherence to specific timing is crucial for some medications. Choices E, F, and G are omitted due to irrelevance.