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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. Takes all antianxiety medications as prescribed.
- D. Learns methods of relaxation to reduce anxiety.
Correct Answer: B
Rationale: Demonstrating effective ways to cope with anxiety is the most important outcome to address the client's self-harming behavior and promote healthier coping mechanisms.
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The nurse completes an assessment of a client experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?
- A. A summary of the client's feelings.
- B. The client's significant other's statement.
- C. A general description.
- D. Photographs.
Correct Answer: D
Rationale: Photographs provide objective and visual documentation of the injuries, offering a clear and accurate record for legal and healthcare purposes.
A female client with obsessive-compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the nurse at bedtime. What action should the nurse implement?
- A. Explain to the client that her behavior invades the rights of the nursing staff.
- B. Teach the client strategies to control her obsessive-compulsive behavior.
- C. Ask the client to explain why she is keeping a detailed record of her nursing care.
- D. Encourage the client to express her feelings regarding the upcoming procedure.
Correct Answer: D
Rationale: Encouraging the client to express feelings regarding the upcoming procedure addresses potential anxiety driving the behavior, offering a therapeutic approach.
A client with chronic alcohol dependency is admitted due to a recent relapse. Which findings should the nurse expect this client to exhibit? (Select all that apply)
- A. Decreased prothrombin time and partial thromboplastin levels.
- B. Increased values of serum levels for liver function profile.
- C. Increasingly larger amounts of alcohol are needed to feel drunk.
- D. Periodic indigestion with negative occult blood in stool.
- E. Memory lapses of events that occurred when drinking.
Correct Answer: B,C,D,E
Rationale: Increased liver function profile values, tolerance to alcohol, indigestion, and memory lapses are common in chronic alcohol dependency, reflecting liver damage, tolerance, gastrointestinal issues, and blackouts.
A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit's day room. Which action should the nurse implement first?
- A. Sit in the chair next to the client.
- B. Listen to what the client is saying.
- C. Escort the client to his room.
- D. Administer a PRN sedative.
Correct Answer: B
Rationale: Listening to what the client is saying helps understand the hallucinations' content, providing insight for appropriate intervention.
An adult client presents to the community mental health center accompanied by the client's spouse who reports that the client has been acting impulsively. The client has spent a large amount of money lately, made several last-minute decisions to take trips, sleeps only 2 to 4 hours a night, and has lost 33 pounds (15 kg) in the last 2 months. Which nursing problem has the greatest nursing priority?
- A. Sleep deprivation related to state of hyperactivity.
- B. Ineffective coping related to biochemical changes.
- C. Risk for self-directed violence related to impulsive behavior.
- D. Imbalanced nutrition related to caloric expenditure.
Correct Answer: C
Rationale: The client's impulsive behavior increases the risk of self-directed violence, making it the most urgent nursing priority due to potential immediate harm.