Nokea
The nurse is caring for a client who has selected transcranial magnetic stimulation to treat depression. For which side effect would the nurse provide preprocedural instructions?
- A. Headache
- B. Blurred vision
- C. Hearing loss
- D. Vertigo
Correct Answer: A
Rationale: The most frequent side effect following transcranial magnetic stimulation to treat depression is headache. Preprocedural instruction would include the most common symptom (headache) and interventions (pain management). Blurred vision, hearing loss, and vertigo are not common side effects.
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Which nursing consideration is most important when administering medications to a suicidal client?
- A. Do not leave any syringe unattended.
- B. Watch the client place all pills in the mouth.
- C. View the inside of the mouth to make sure that all medications are swallowed.
- D. Remove all medications and medication administration equipment from client area.
Correct Answer: C
Rationale: It is most important for the nurse to view the inside of the mouth when administering medications. This is done by inspecting the client's mouth and under the tongue because clients may 'cheek' medications to stockpile and use the medications. Not leaving syringes unattended, watching the client place the pills in their mouth, and removing all medications and equipment are all appropriate nursing actions, but the most important is not allowing the opportunity for the client to overdose on medications.
The nurse is admitting a client to a mental health clinic following a recent suicide attempt and hospitalization. In assessing the client's status, which question is most helpful?
- A. How are you currently feeling?
- B. What made you decide to commit suicide?
- C. Do you have a suicide plan or thoughts of harming yourself?
- D. What method did you choose for your suicide attempt?
Correct Answer: C
Rationale: In assessing the client's status, it is best to evaluate suicide risk factors. A client who is at the highest risk for suicide is the client who verbalizes a desire to end life and has a plan. The other questions are relevant but not the best question for gaining essential information.
Which of the following nursing diagnoses is of highest priority when caring for a client who is depressed and considers suicide?
- A. Suicide Attempt Risk
- B. Injury Risk
- C. Sleep Deprivation
- D. Coping Impairment
Correct Answer: A
Rationale: Clients with a nursing diagnosis of Suicide Attempt Risk are at an increased risk for suicide due to their feeling of despair. Providing nursing interventions that recognize the client's mood and maintain safety is essential. The other nursing diagnoses are also important and may also be appropriate but are not of the highest priority.
The nurse is completing a plan of care for a client on lithium therapy to manage bipolar symptoms. Which nursing intervention(s) will be included? Select all that apply.
- A. Monitor for symptoms of nausea, vomiting, muscle weakness, and lack of coordination.
- B. Increase fluid intake to 5000 mL/day.
- C. Limit sodium intake daily.
- D. Monitor kidney and liver functioning.
- E. Instruct client that it may take up to 6 weeks to reach therapeutic level.
- F. Monitor intake and output.
Correct Answer: A,B,D,F
Rationale: The nurse is correct to place in the plan of care interventions that include monitoring for symptoms of lithium toxicity, increasing fluid intake to maintain fluid balance, monitoring kidney and liver function, and monitoring intake and output. Salt intake is important to regulate lithium levels in the body. A therapeutic lithium level is accomplished in a few days to a week.
Which type of therapy is facilitated by a bond that develops between the therapist and the client?
- A. Behavioral therapy
- B. Supportive psychotherapy
- C. Interpersonal psychotherapy
- D. Cognitive therapy
Correct Answer: C
Rationale: Interpersonal psychotherapy is facilitated by a bond that develops between the therapist and the client. Behavioral therapy endeavors to change unhealthy ways of behaving. Supportive psychotherapy helps clients learn about their disorder and treatment techniques, improve or develop new social skills, and gain encouragement to persevere. Cognitive therapy helps clients replace negative, and often illogical, ways of thinking with more positive outlooks.