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The nurse is planning the care for a 32-year-old male client with acute depression. Which nursing intervention would be best in helping this client deal with his depression?
- A. Ensure that the client's day is filled with group activities.
- B. Assist the client in exploring feelings of shame, anger, and guilt.
- C. Allow the client to initiate and determine activities of daily living.
- D. Encourage the client to explore the rationale for his depression.
Correct Answer: B
Rationale: Assisting the client in exploring feelings of shame, anger, and guilt (B) is the most appropriate intervention for acute depression as it helps address core emotions that may be contributing to the condition. Focusing on these emotions can aid the client in processing and coping with their feelings. Ensuring that the client's day is filled with group activities (A) might overwhelm the client, as they may not be ready for social interactions during this sensitive time. Allowing the client to initiate and determine activities of daily living (C) is more suitable for chronic cases where the client needs to regain autonomy. Encouraging the client to explore the rationale for his depression (D) is less effective in acute cases, as the focus should be on immediate emotional support and understanding rather than cognitive analysis.
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A male client with schizophrenia tells the nurse that the voices he hears are saying, 'You must kill yourself.' To assist the client in coping with these thoughts, which response is best for the nurse to provide?
- A. Tell yourself that the voices are unreasonable.'
- B. Exercise when you hear the voices.'
- C. Talk to someone when you hear the voices.'
- D. The voices aren't real, so ignore them.'
Correct Answer: A
Rationale: The nurse should teach the client to use self-talk to disprove the voices. Although exercising may be helpful, the client's concrete thinking may make it difficult to understand this suggestion. Clients with schizophrenia have difficulty initiating interaction with others. Auditory hallucinations are often relentless, so it is difficult to ignore them.
A client in the manic phase of bipolar disorder is pacing the hallway and talking rapidly. What is the best intervention for the nurse?
- A. Encourage the client to join a group activity.
- B. Offer the client a high-calorie snack and a drink.
- C. Direct the client to a quieter area of the unit.
- D. Instruct the client to sit down and relax.
Correct Answer: B
Rationale: In the manic phase of bipolar disorder, clients often exhibit increased activity and may burn a lot of energy. Offering a high-calorie snack and a drink is the best intervention as it helps maintain their nutritional needs while allowing them to continue their activity. Encouraging the client to join a group activity (Choice A) may further stimulate their behavior. Directing the client to a quieter area (Choice C) might not address their energy expenditure. Instructing the client to sit down and relax (Choice D) may not be effective during the manic phase.
A female client with obsessive compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving and reports her findings to the RN at bedtime. What action should the nurse implement?
- A. Explain to the client that her behavior invades the rights of the nursing staff.
- B. Ask the client to explain why she is keeping a detailed record of her nursing care.
- C. Teach the client strategies to control her obsessive compulsive behavior.
- D. Encourage the client to express her feelings regarding the upcoming procedure.
Correct Answer: D
Rationale: Encouraging the client to express her feelings can help address underlying anxieties and may reduce the need for obsessive behaviors. Choice A is incorrect because it may come across as confrontational and could escalate the situation. Choice B is not the best initial action as it focuses on the behavior rather than the client's emotions. Choice C is premature without first addressing the client's emotional needs.
A client with bipolar disorder is being treated with lithium. The nurse should monitor the client for which early sign of lithium toxicity?
- A. Diarrhea
- B. Tremors
- C. Polyuria
- D. Blurred vision
Correct Answer: A
Rationale: Corrected Rationale: Diarrhea is an early sign of lithium toxicity. When a client being treated with lithium presents with diarrhea, it can indicate the beginning of lithium toxicity. Monitoring for this symptom is crucial as it can progress to more severe toxicity if not addressed promptly. Tremors (choice B) are more commonly associated with the therapeutic effects of lithium rather than toxicity. Polyuria (choice C) is a common side effect of lithium, but it is not typically an early sign of toxicity. Blurred vision (choice D) is not a common early sign of lithium toxicity. Therefore, option A is the correct answer.
The nurse is leading a 'current events group' with chronic psychiatric clients. One group member states, 'Clara Barton was my nurse during my last hospitalization. She was a very mean nurse and wasn't nice to me.' Which response would be best for the nurse to make?
- A. 'Clara Barton was not your nurse.'
- B. 'What did she do to you that was so mean?'
- C. 'I didn't know that Clara Barton was a nurse.'
- D. 'Clara Barton started the American Red Cross.'
Correct Answer: D
Rationale: (D) presents the reality of the situation in relation to American culture. The fact that Clara Barton was a nurse during the Civil War should be addressed on an individual basis. Since this is group therapy, the nurse would be illustrating the concept of universality. (A) is likely to promote defensiveness. (B and C) would support the delusion. Therefore, the most appropriate response is (D) as it provides factual information that can redirect the conversation in a constructive manner.