Nokea
The nurse is interviewing a client being admitted to the mental health inpatient unit who was involved in a fire 2 months ago. The client is reporting insomnia, difficulty concentrating, nervousness, hypervigilance, and frequently thinking about fires. The nurse should recognize these complaints to be indications of which disorder?
- A. Phobia
- B. Dissociative disorder
- C. Obsessive-compulsive disorder
- D. Post-traumatic stress disorder (PTSD)
Correct Answer: D
Rationale: PTSD is precipitated by events that are overwhelming, unpredictable, and sometimes life threatening. Typical symptoms of PTSD include difficulty concentrating, sleep disturbances, intrusive recollections of the traumatic event, hypervigilance, and anxiety. These symptoms are not characteristic of the disorders noted in options 1, 2, and 3.
You may also like to solve these questions
The nurse is caring for an older client who has been placed in Buck's extension traction after a hip fracture. During the assessment of the client, the nurse notes that the client is disoriented. Which is the most appropriate nursing intervention for this client?
- A. Apply restraints to the client.
- B. Ask the family to stay with the client.
- C. Ask the laboratory to perform electrolyte studies.
- D. Reorient the client to time, place, and person frequently.
Correct Answer: D
Rationale: An inactive older person may become disoriented as a result of a lack of sensory stimulation. The appropriate nursing intervention would be to frequently reorient the client and place objects such as a clock and a calendar in the client's room to maintain orientation. Restraints may cause further disorientation and should not be applied unless specifically prescribed. Agency policies and procedures should be followed before the application of restraints. The family can assist with the orientation of the client, but it is not appropriate to ask the family to stay with the client. It is not within the scope of nursing practice to prescribe laboratory studies.
A male client is admitted to the hospital diagnosed with diabetic ketoacidosis (DKA). The client's daughter says to the nurse, 'My mother died last month, and now this. I've been trying to follow all of the instructions the doctor gave my dad, but what have I done wrong?' Which therapeutic response should the nurse make to the client's daughter?
- A. Tell me what you think you did wrong.'
- B. Maybe we can keep your father in the hospital for a while longer to give you a rest.'
- C. You should talk to the social worker about getting you someone at home who has more experience managing a diabetic's care.'
- D. An emotional stress such as your mother's death can trigger DKA in a diabetic client, even though the prescribed regimen is being followed.'
Correct Answer: D
Rationale: Environment, infection, or an emotional stressor can initiate the physiological mechanism of DKA. Options 1 and 3 substantiate the daughter's feelings of guilt and incompetence. Option 2 is not a cost-effective intervention.
The nurse is developed a teaching plan for a client prescribed spironolactone. On which psychosocial side effect of the medication should the nurse base the teaching plan?
- A. Edema
- B. Hair loss
- C. Weight loss
- D. Decreased libido
Correct Answer: D
Rationale: The nurse should be aware of the fact that the client taking spironolactone, a potassium-sparing diuretic, may experience body image changes that result from a threatened sexual identity. These are related to decreased libido, gynecomastia in males, and hirsutism in females. Edema, weight loss, and hair loss are not specifically associated with the use of this medication.
A nurse has admitted a client to the mental health unit following an attempted suicide. The client also attempted suicide four months earlier. Which is the best way to ensure client safety?
- A. give the client a task to do, such as folding towels, to distract him
- B. assign a staff member to remain with the client one-on-one at all times
- C. obtain an order for chemical and physical restraints to be used as needed
- D. keep the client in the day room around other clients who can help watch the client
- E. place the client in isolation after removing potentially unsafe articles, such as shoelaces and belts
Correct Answer: B
Rationale: One-on-one supervision is the most effective way to ensure safety for a client with recent suicide attempts, as it allows immediate intervention if needed.
A client in the long-term care facility is confused and repeatedly asks the nurse for help finding the assigned room. Which response by the nurse is appropriate?
- A. Here is a map of the facility, including the room numbers.
- B. I think you can find your room if you just concentrate.
- C. Your room is on the first floor by the elevator doors.
- D. You didn't have any trouble finding your room yesterday.
Correct Answer: C
Rationale: Providing a clear, specific direction (room location by the elevator) helps orient the confused client without frustration. Maps are too complex, urging concentration is unhelpful, and referencing past ability may cause distress.