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The nurse conducts a grief support group at the community mental health center. Which client will the nurse identify as needing additional assistance before participating in this group?
- A. Older adult male whose estranged spouse, living in another state, died from heart disease 3 months ago.
- B. Older adult female whose spouse died 3 years ago in a car accident.
- C. Middle-aged female who started drinking after the sudden death of the spouse 6 months ago.
- D. Young male with two children whose spouse died 1 year ago due to breast cancer.
Correct Answer: C
Rationale: The middle-aged female who began drinking after her spouse’s death indicates unhealthy coping and potential substance abuse, requiring individual intervention before group participation. Other clients show grief but no immediate maladaptive behaviors.
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The mental health nurse is caring for a client with Cluster B personality disorder. The nurse would expect the client to exhibit which behaviors? Select all that apply.
- A. suspicious of others, magical thinking, eccentric behavior, paranoia, relationship deficits
- B. preoccupation with rules and details, hoarding, ritualistic behavior, extremely devoted to work
- C. easily bored, poor and shallow interpersonal relationships, enjoys being the center of attention
- D. impulsivity, unpredictable behavior, extreme mood shifts, easily angered, playing people against each other
- E. suspicious and untrusting of others, argumentative, controlling of others, thoughts of grandiosity
Correct Answer: C,D
Rationale: Cluster B personality disorders (e.g., histrionic, borderline) involve attention-seeking, shallow relationships, impulsivity, and mood instability. Options A and E describe Cluster A, and B describes Cluster C.
The nurse is caring for a client during a precipitous labor. The nurse should anticipate that the client will require care for which emotional need?
- A. Support in maintaining a sense of control
- B. Less pain and anxiety than with a normal labor
- C. A sense of satisfaction regarding her quick labor
- D. Fewer fears regarding the effect of labor on the newborn infant
Correct Answer: A
Rationale: The client experiencing a precipitous labor may have more difficulty maintaining control because of the abrupt onset and quick progression of the labor. This may be very different from previous labor experiences; therefore, the client needs support from the nurse to understand and adapt to the rapid progression. The contractions often increase in intensity very quickly, which adds to the client's pain, anxiety, and lack of control. The client may also have an increased amount of concern about the effect of the labor on the newborn infant. A lack of control over the situation in combination with increased pain and anxiety can result in a decreased level of satisfaction with the labor and delivery experience.
Fluoxetine hydrochloride is prescribed for a client with a diagnosis of depression. The nurse provides instructions to the client regarding the administration of the medication. Which statement by the client indicates an understanding about administration of the medication?
- A. I should take the medication with my evening meal.
- B. I should take the medication at noon with an antacid.
- C. I should take the medication in the morning when I first arise.
- D. I should take the medication right before bedtime with a snack.
Correct Answer: C
Rationale: Fluoxetine hydrochloride is an antidepressant and is administered in the early morning without consideration of meals. The remaining options present either incorrect times or incorrect conditions to take this medication.
The nurse is caring for an older client who has been placed in Buck's extension traction after a hip fracture. During the assessment of the client, the nurse notes that the client is disoriented. Which is the most appropriate nursing intervention for this client?
- A. Apply restraints to the client.
- B. Ask the family to stay with the client.
- C. Ask the laboratory to perform electrolyte studies.
- D. Reorient the client to time, place, and person frequently.
Correct Answer: D
Rationale: An inactive older person may become disoriented as a result of a lack of sensory stimulation. The appropriate nursing intervention would be to frequently reorient the client and place objects such as a clock and a calendar in the client's room to maintain orientation. Restraints may cause further disorientation and should not be applied unless specifically prescribed. Agency policies and procedures should be followed before the application of restraints. The family can assist with the orientation of the client, but it is not appropriate to ask the family to stay with the client. It is not within the scope of nursing practice to prescribe laboratory studies.
A client diagnosed with myasthenia gravis is ready to return home. The client confides that she is concerned that her significant other will no longer find her physically attractive. Which client-focused action should the nurse encourage in the plan of care?
- A. Attend a support group.
- B. Cease dwelling on the negative.
- C. Reach out for help to face this fear.
- D. Share her feelings with her partner.
Correct Answer: D
Rationale: Talking to the client about sharing her feelings with her husband directly addresses the subject of the question. Encouraging the client to start a support group will not address the client's immediate and individual concerns. Options 2 and 3 are blocks to communication and avoid the client's concern.