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The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?
- A. Participates in individual and group therapy
- B. Demonstrates effective ways to cope with anxiety
- C. Learns methods of relaxation to reduce anxiety
- D. Takes all antianxiety medications as prescribed
Correct Answer: B
Rationale: This outcome directly addresses the client's maladaptive coping mechanism (scratching wrists) by aiming to replace it with healthier strategies. Therapy participation and relaxation methods are important but secondary to effective coping. Medication adherence does not teach alternative coping strategies.
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A client with a history of alcoholism is admitted for detoxification. Based on treatment protocol, the nurse gives the client a dose of lorazepam 6 mg. Which additional prescription should the nurse administer immediately?
- A. Folic Acid
- B. Haloperidol
- C. Trazodone
- D. Vitamin B1
Correct Answer: D
Rationale: Vitamin B1 (thiamine) is crucial in alcohol detoxification to prevent Wernicke's encephalopathy and Korsakoff's syndrome due to thiamine deficiency. Folic acid is beneficial but not immediate. Haloperidol and trazodone are not indicated for detoxification.
Mark whether the statement by the student nurse indicates understanding or no understanding.
- A. If the client decides not to report their friend to the police, it is still a good idea to collect the evidence': Understanding
- B. Even if the client will not call the police, the nurse should advise the police of what has happened': No understanding
- C. The client has to consent in order for me to document his injuries in the chart': Understanding
- D. Consent is not required to collect evidence from a person who has been sexually assaulted': No understanding
- E. The sexual assault exam should only be done by a Sexual Assault Nurse Examiner, the Emergency Room attending physician, or other expert': Understanding
Correct Answer: A,B,C,D,E
Rationale: A: Collecting evidence preserves options (Understanding). B: Reporting without consent violates autonomy (No understanding). C: Consent is required for documentation (Understanding). D: Consent is always required for evidence collection (No understanding). E: Exams require trained professionals (Understanding).
The nurse is performing the admission assessment for a client with schizophrenia in an acute care inpatient facility. The nurse should identify which observed behavior is characteristic of schizophrenia?
- A. Responds with illogical answers to questions
- B. Admits to frequently thinking about committing suicide
- C. Describes times of depression followed by feelings of euphoria
- D. Exhibits compulsive, ritualistic behaviors
Correct Answer: A
Rationale: Responding with illogical answers indicates disorganized thinking, a hallmark of schizophrenia during psychosis. Suicide thoughts are not specific to schizophrenia. Depression and euphoria suggest bipolar disorder. Compulsive behaviors are more typical of OCD.
An adolescent who was arrested a month ago for gang-related activities has a court order to attend weekly group therapy sessions at the mental health clinic. Today the adolescent's mother calls the clinic nurse to report that her child became angry last night and put a fist through a window. Which intervention is most important for the nurse to implement?
- A. Reinforce the need for the adolescent to attend group therapy sessions
- B. Tell the mother to describe her feelings of helplessness to her child
- C. Advise the mother to call the police if violent behavior occurs again
- D. Refer the mother for psychiatric evaluation for anxiety and depression
Correct Answer: C
Rationale: Advising the mother to call the police if violent behavior recurs prioritizes safety for the adolescent and household. Therapy attendance is important but secondary to immediate safety. Discussing the mother's feelings or referring her for evaluation does not address the acute risk.
The nurse has received a new prescription for the client to begin taking sertraline. Prior to administering the initial dose of sertraline, it is most important for the nurse to obtain which information?
- A. Any history of heart disease
- B. Familial history of mental illness
- C. Medication history
- D. Current weight
Correct Answer: C
Rationale: Obtaining a thorough medication history is essential to identify potential drug interactions, allergies, or contraindications for sertraline. Heart disease history is relevant but less critical. Familial mental illness history is not immediately necessary. Weight does not typically affect sertraline dosing.