Nokea
The nurse is developing unit policies that will include nursing guidelines for maintaining a therapeutic milieu. Which interventions should be included when providing a therapeutic milieu in an inpatient setting?
- A. Opportunities to contribute to one's treatment plan.
- B. One-on-one dialogue sessions with the therapist.
- C. Regularly scheduled unit activities for peer interaction.
- D. Home visits to reintegrate into the family.
Correct Answer: C
Rationale: The nurse is responsible for maintaining a therapeutic milieu in an inpatient setting, which involves creating a secure and structured environment that promotes client safety and offers opportunities for clients to learn healthy coping skills. Regularly scheduled unit activities for peer interaction help foster socialization, support, and a sense of community among clients. Choices A and B are valuable interventions in mental health care but do not directly relate to creating a therapeutic milieu in an inpatient setting. Choice D, home visits, would typically occur post-discharge and focus on community reintegration, rather than maintaining a therapeutic milieu within the inpatient setting.
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The nurse accepts a transfer to the mental health unit and understands that the client is distractible and is exhibiting a decreased ability to concentrate. The nurse has only 15 minutes to talk with the client. To develop a treatment plan for this client, which assessment is most important for the nurse to obtain?
- A. Motivation for treatment
- B. History of substance use
- C. Medication compliance
- D. Mental status examination
Correct Answer: D
Rationale: A mental status examination is the most important assessment for the nurse to obtain in this scenario. It provides a comprehensive view of the client's current cognitive functioning, including their level of alertness, orientation, memory, attention, and thought process. Understanding the client's mental status is crucial for developing an appropriate treatment plan. The other options, such as motivation for treatment, history of substance use, and medication compliance, are important aspects to consider but may not directly address the client's current cognitive state and immediate treatment needs as effectively as a mental status examination.
A client is being treated for generalized anxiety disorder (GAD) and is prescribed an SSRI. Which side effect should the nurse educate the client about?
- A. Weight loss
- B. Increased appetite
- C. Insomnia
- D. Dry mouth
Correct Answer: C
Rationale: The correct answer is C: Insomnia. Insomnia is a common side effect of SSRIs, including those used to treat generalized anxiety disorder (GAD). Educating the client about potential side effects like insomnia is crucial for managing expectations and promoting treatment adherence. Weight loss (choice A) is less common with SSRIs and might not be a primary concern for a client with GAD. Increased appetite (choice B) is also less likely with SSRIs. Dry mouth (choice D) is a side effect more commonly associated with other classes of medications, such as anticholinergics, rather than SSRIs.
A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the nurse finds him attempting to drink water from the bathroom sink faucet. Which intervention should the nurse implement?
- A. Report the client's serum lithium level to the healthcare provider.
- B. Encourage the client to suck on hard candy to relieve the symptoms.
- C. No action is needed since polydipsia is a common side effect.
- D. Tell the client that drinking from the faucet is not allowed.
Correct Answer: B
Rationale: Encouraging the client to suck on hard candy is the appropriate intervention as it can help alleviate the sensation of excessive thirst, which is a common side effect of lithium. Reporting the client's serum lithium level to the healthcare provider may be needed if there are signs of lithium toxicity, but the priority here is to address the immediate symptom of excessive thirst. Polydipsia, or excessive thirst, is a known side effect of lithium, but it should not be left unaddressed. Simply telling the client that drinking from the faucet is not allowed does not address the underlying issue of excessive thirst and may lead to further distress.
A male client with a long history of alcohol dependency arrives in the emergency department describing the feeling of bugs crawling on his body. His BP is 170/102, pulse rate is 110 bpm, and his blood alcohol level (BAL) is 0 mg/dl. Which medication should the nurse administer?
- A. Haloperidol (Haldol)
- B. Thiamine (Vitamin B1)
- C. Diphenhydramine (Benadryl)
- D. Lorazepam (Ativan)
Correct Answer: D
Rationale: In this scenario, the client is experiencing hallucinations and symptoms of alcohol withdrawal. Lorazepam (Ativan) is the appropriate choice as it helps manage withdrawal symptoms, including hallucinations and elevated blood pressure in alcohol-dependent clients. Haloperidol (Haldol) (Choice A) is an antipsychotic but is not the first-line treatment for alcohol withdrawal symptoms. Thiamine (Vitamin B1) (Choice B) is essential in alcohol withdrawal treatment for preventing Wernicke's encephalopathy, but in this case, addressing the acute withdrawal symptoms is the priority. Diphenhydramine (Benadryl) (Choice C) is an antihistamine that may help with itching or mild anxiety but is not the preferred choice for managing alcohol withdrawal symptoms like hallucinations and elevated blood pressure.
A healthcare professional is preparing to provide medication education to a client who has just been prescribed an antipsychotic medication. What should the healthcare professional include in the teaching plan?
- A. "You should have regular eye exams."
- B. "It is important to avoid caffeine while on this medication."
- C. "You may experience dry mouth and blurred vision."
- D. "You should increase your intake of vitamin C to prevent side effects."
Correct Answer: C
Rationale: The correct answer is C. Antipsychotic medications often have anticholinergic side effects like dry mouth and blurred vision. Teaching the client about these potential side effects is essential for their understanding and management. Regular eye exams (Choice A) are not specifically related to antipsychotic medications. While avoiding caffeine (Choice B) might be a general good practice, it is not a specific side effect of antipsychotic medications. Increasing vitamin C intake (Choice D) is not a standard recommendation for preventing antipsychotic medication side effects.