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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.
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An adolescent who is a heroin addict is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?
- A. Assess intake and output.
- B. Monitor for wheezing and apnea.
- C. Limit visitors to family members only.
- D. Assign the client to a teen support group.
Correct Answer: B
Rationale: Monitoring for wheezing and apnea is crucial during the first 24 hours of heroin detoxification to ensure respiratory stability, addressing immediate physiological risks.
Which individual should the nurse consider at the highest risk for suicide?
- A. A nurse who works in a pediatric emergency department.
- B. An adolescent male whose parents recently divorced.
- C. A retired older male whose significant other has passed away.
- D. A single working mother with three preschool-aged children.
Correct Answer: B
Rationale: Adolescents experiencing major life changes, such as parental divorce, are at an elevated risk for suicide due to emotional and social stressors.
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 is crucial to understand the content and nature of the auditory hallucinations, guiding further interventions.
A client diagnosed with schizophrenia has been receiving haloperidol for the past year, and the treatment plan includes moving the client to a lower maintenance dosage. Which intervention should the nurse include in this client's plan of care? (Select all that apply)
- A. Shielding the client from direct sunlight when outdoors.
- B. Gradually withdrawing the medication over several days.
- C. Enforcing a fluid restriction during dosage adjustment.
- D. Increasing the dosage if the white blood cell count drops.
Correct Answer: A,B
Rationale: Shielding from sunlight prevents sunburn due to haloperidol's photosensitivity, and gradual withdrawal avoids symptom worsening.
A client with post-traumatic stress disorder (PTSD) is experiencing a dissociative disorder episode. The situation quickly escalates, and the client becomes physically aggressive. Which intervention should the nurse implement first?
- A. Request a team member to assist with seclusion and restraint.
- B. Administer lorazepam 1.5 mg intramuscularly twice daily as needed.
- C. Confirm the client's identity and orientation to time and place.
- D. Inspect the area for objects that can be used in a dangerous manner.
- E. None.
- F. None.
Correct Answer: D
Rationale: Inspecting the area for dangerous objects is the first priority to ensure safety during the client's aggressive behavior.