Nokea
The nurse is caring for a client with a disturbance in thought process who is disoriented and aggressive. What nursing action may produce further agitation?
- A. Speaking in slow, brief sentences
- B. Presenting the reality of the situation
- C. Allowing the client freedom in a confined area
- D. Being present without speaking
Correct Answer: B
Rationale: When caring for a client with a disturbed thought process, presenting the reality of a situation may create conflict and confusion. Also, this can lead to a verbal exchange and escalation in agitation by the client. Actions by the nurse include attempts to decrease tension and anxiety such as speaking in slow, brief sentences so the client can comprehend instructions. Allow the client freedom when maintaining a safe environment. Being present to support and assist the client without speaking is less likely to produce agitation.
You may also like to solve these questions
A nurse is caring for a client newly admitted to the emergency department. The nurse obtains the following vital signs: temperature, 101.6?°F; pulse rate, 92 beats/minute; respiratory rate, 28 breaths/minute; and blood pressure, 160/90 mmHg. The client appears disheveled and disoriented. Upon physical assessment, the nurse notes restlessness and muscle spasms with rigidity. Which documented finding in the health history is evaluated as a potential causative factor?
- A. Mixing antibiotics with psychotherapeutic medications
- B. Changing from one psychotherapeutic to another
- C. Initiating psychotherapeutic drug therapy
- D. Combining dairy products with psychotherapeutics
Correct Answer: B
Rationale: Serotonin syndrome is a potentially life-threatening condition that results from elevated levels of serotonin in the blood secondary to drug therapy. When reviewing the client's medication history and relating the symptoms assessed, the nurse relates the client's status with changing from one psychotherapeutic to another psychotherapeutic medication as a potential causative factor. There is no correlation from the client symptoms to combining antibiotic therapy with psychotherapeutics, initiating psychotherapeutics, or combining dairy products with psychotherapeutics.
Which observation(s) is helpful in determining a client's mood? Select all that apply.
- A. Client appearance
- B. Body language
- C. Speech
- D. Energy level
- E. Work history
Correct Answer: A,B,C,D
Rationale: The nurse can gather observational data using the assessment skill of inspection. Client appearance that is disheveled indicates signs of personal neglect. Body language may indicate evidence of anxiety, anger, or depression. Pace of speaking and energy level indicates mania or depression. Work history can be helpful in determining information related to a client's ability to fit in socially but is not included in observational data.
The nurse is providing teaching to a client starting monoamine oxidase inhibitor (MAOI) drug therapy. Which over-the-counter medications should the nurse instruct the client to avoid?
- A. Cold and allergy medications
- B. Antiulcer medications
- C. Multivitamins
- D. Laxatives
Correct Answer: A
Rationale: The nurse is correct to place cold and allergy medications on a clinical reference guide of over-the-counter medications to avoid. These preparations may have a drug-drug interaction. The client can use over-the-counter antiulcer medications, multivitamins, and laxatives per physician instruction.
The nurse is providing instruction to a community class regarding seasonal affective disorder (SAD). Which gland and hormone would the nurse stress is responsible?
- A. Thyroid gland and thyroxin
- B. Pineal gland and melatonin
- C. Pancreas and insulin
- D. Pituitary gland and oxytocin
Correct Answer: B
Rationale: The hypothalamus relays the light-sensing data from the sun to the pineal gland. The pineal gland regulates the hormone melatonin. Melatonin also affects the regulation of serotonin, which affects mood.
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.