Nokea
The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the client's history should the nurse further explore?
- A. Family history of dementia.
- B. Witness to an accident.
- C. Alcohol use.
- D. Inadequate diversional activity.
Correct Answer: C
Rationale: Alcohol use can contribute to sleep disturbances, including nightmares, making it a critical factor to explore in relation to the client's symptoms.
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The nurse is caring for a client who is a refugee from another country and who is experiencing daily episodes of anxiety. The client communicates minimally with the nurse, looking away and appearing distressed. Which intervention is most important for the nurse to do first?
- A. Reinforce personal strengths observed in the client.
- B. Suggest ways to problem solve adapting to the new home.
- C. Help the client know they will not always feel this way.
- D. Inquire respectfully about the events of the departure.
Correct Answer: D
Rationale: Inquiring respectfully about the events of departure is critical to understand potential traumatic experiences contributing to the client's anxiety.
When a male client is asked about his reason for coming to the mental health clinic, he replies, “It all started because I work in a hostile work environment. My boss would not let me go to a religious service, so I went to human resources, and they didn't want to do anything. It has been a really difficult time for me.†Which response should the nurse provide?
- A. Why do you think you have a hostile work environment?
- B. Have you considered resigning from your position?
- C. Have the feelings associated with these events brought you to the clinic?
- D. How have you responded to those in your work environment about these events?
Correct Answer: C
Rationale: This response acknowledges the client's feelings and experiences, allowing for further exploration of the issues that brought him to the clinic, fostering therapeutic communication.
An adolescent female with an eating disorder is admitted to the in-patient psychiatric unit. Which intervention should the nurse implement?
- A. Encourage the client to weigh herself daily at bedtime.
- B. Recommend exercise and recreation in the morning.
- C. Allow the client to select an arts and crafts activity.
- D. Put the client in charge of choosing snacks for the unit.
Correct Answer: C
Rationale: Allowing the client to select an arts and crafts activity provides a positive, non-food-related outlet for expression, supporting therapeutic engagement.
A client is admitted to an inpatient psychiatric unit, and the antipsychotic medication clozapine is prescribed. Which intervention should the nurse include in this client's plan of care?
- A. Inform unlicensed assistive personnel (UAP) that the client will likely complain of a sore throat and fever.
- B. Place the client in protective isolation for the first two weeks of treatment with this medication.
- C. Offer this medication to the client with food to decrease the possibility of gastric upset.
- D. Report findings from the client's weekly white blood cell (WBC) counts to the healthcare provider.
Correct Answer: D
Rationale: Clozapine is associated with the risk of agranulocytosis, so regular monitoring of WBC counts and reporting findings to the healthcare provider is essential.
A male client, assessed in the emergency department (ED), has a strong odor of alcohol on his breath. The client denies thoughts of harm to self or others, and the healthcare provider discharges the client. As the client begins to leave, the nurse overhears the client mumble, “Now I'm going to shoot myself.†Which intervention should the nurse implement?
- A. Inquire about the client's support system.
- B. Ask the client to repeat his comment.
- C. Stop the client from leaving the ED.
- D. Record the statement in the client's chart.
Correct Answer: C
Rationale: Stopping the client from leaving the ED is the priority to ensure safety and prevent potential self-harm based on the overheard statement.