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The nurse is planning care for a child who has intermittent explosive disorder (IED). The nurse should identify which of the following goals are appropriate for this client? (Select All that Apply.)
- A. The child will demonstrate effective problem-solving skills.
- B. The child will acknowledge they have a genetic disorder.
- C. The child will verbalize age-appropriate feelings of self-worth.
- D. The family will be able to express their concerns.
- E. The child will sign a behavior contract.
- F. The child will learn to isolate when feeling angry.
Correct Answer: A,E,F
Rationale: Correct Answer: A, E, F
Rationale:
A: The child demonstrating effective problem-solving skills is crucial for managing IED episodes.
E: Signing a behavior contract helps set clear expectations and consequences for behavior, aiding in self-regulation.
F: Learning to isolate when feeling angry can prevent harm and give time to calm down, a key skill for managing IED.
Incorrect Choices:
B: Acknowledging a genetic disorder is not relevant to managing IED.
C: While important, verbalizing feelings of self-worth may not directly address the impulsivity of IED.
D: Expressing concerns is valuable but not a direct goal for managing IED.
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A nurse is condu,a client diagnosed with schizophrenia jumps up and runs out while yelling You are all making fun of me. The nurse recognizes that the client is displaying which of the following behaviors?cting a group therapy meeting and shares a humorous story. When the group laughs at the story
- A. Flight of ideas
- B. Erotomania
- C. Grandeur
- D. Ideas of reference
Correct Answer: D
Rationale: The correct answer is D: Ideas of reference. This behavior is exhibited when a person believes that neutral events or actions are directed at them personally. In this scenario, the client with schizophrenia perceives others are making fun of them when that may not be the case. This demonstrates a misinterpretation of external stimuli. Flight of ideas (A) refers to rapidly shifting from one idea to another. Erotomania (B) is a delusion where someone believes another person is in love with them. Grandeur (C) involves exaggerated beliefs of one's importance or power.
A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting,and now the client is pacing up and down the hallways of the unit. Which of the following actions should the nurse take?
- A. Instruct the client to sit down and stop pacing.
- B. Allow the client to pace alone until physically tired.
- C. Have a staff member escort the client to her room.
- D. Walk with the client at a gradually slower pace.
Correct Answer: D
Rationale: Walking with the client calmly reduces anxiety while providing support.
A nurse is teaching a female client who has an anxiety disorder and is prescribed alprazolam (Xanax). Which of the following information should the nurse include in the teaching?
- A. If a dose is missed, do not double the next dose of medication.
- B. This medication may cause dizziness upon standing.
- C. Use a dependable form of contraception while taking this medication.
- D. Do not drink alcohol while taking this medication.
Correct Answer: B
Rationale: The correct answer is B: This medication may cause dizziness upon standing. Alprazolam is a benzodiazepine that can cause dizziness as a side effect, especially when standing up quickly. This information is important for the client to prevent falls or accidents.
A: Missing a dose should not be addressed by doubling the next dose as it can lead to overdose or adverse effects.
C: Although contraceptives might be important to discuss, it is not specifically related to the medication itself.
D: Alcohol should be avoided while taking alprazolam due to the increased risk of side effects and potential interactions, but it is not the most crucial information for the client's safety.
According to Bowen's theoretical approach to therapy,which of the following should the nurse recognize as a concept of a functional family interaction pattern?
- A. Marital skew
- B. Sibling position
- C. Double-bind communication
- D. Pseudomutuality
Correct Answer: B
Rationale: According to Bowen's theoretical approach, sibling position is a concept of a functional family interaction pattern. This refers to the role and position each sibling holds within the family system, influencing their behavior and relationships. Understanding sibling positions helps assess family dynamics and interactions. Marital skew, double-bind communication, and pseudomutuality are not specific concepts of a functional family interaction pattern in Bowen's theory. Marital skew refers to imbalance in spousal relationships, double-bind communication involves conflicting messages, and pseudomutuality is a false sense of harmony.
A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply.)
- A. Weigh the client every 3 to 4 days.
- B. Discourage the client from taking a nap during the day.
- C. Monitor vital signs throughout the day.
- D. Offer nutritional foods to the client every 2 hours.
- E. Maintain an environment with low stimuli.
Correct Answer: B,C,D,E
Rationale: The correct interventions are B, C, D, and E. B: Discouraging naps helps regulate sleep patterns in mania. C: Monitoring vital signs is crucial due to potential physical risks. D: Offering frequent, nutritional foods helps stabilize energy levels. E: Low-stimuli environment reduces agitation. A is incorrect as frequent weighing may not be necessary. F and G are not provided but would be incorrect if they do not align with managing mania symptoms.