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The nurse is teaching a group of adolescents about assertive communication. Two of the adolescents are seated at a round table and another is sitting on a small sofa nearby. To facilitate group interaction, which intervention is best for the nurse to implement?
- A. Allow the adolescents to sit wherever they wish as long as they participate.
- B. Suggest that they all sit together to increase interaction.
- C. Ask the adolescent sitting on the couch to join the group at the table.
- D. Determine which adolescents would like to participate in the discussion.
Correct Answer: C
Rationale: Asking the adolescent on the couch to join the table promotes inclusivity and equal participation, enhancing group interaction.
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A client who is an alcoholic receives a prescription for disulfiram 500 mg PO daily. Which instruction should the nurse provide to this client?
- A. Take the medication each morning beginning 48 hours after your last drink of alcohol.
- B. Take the medication with at least 8 ounces of water and limit alcohol consumption while taking this medication.
- C. Take the medication at bedtime and avoid consuming any more than one ounce of alcohol daily.
- D. Begin taking the medication immediately and take it daily, regardless of whether or not you drink alcohol.
Correct Answer: A
Rationale: Disulfiram should be taken each morning, starting 48 hours after the last drink to prevent a severe reaction, establishing a clear association between the medication and alcohol avoidance.
An adolescent male who was arrested a month ago for gang-related activities has a court order to attend weekly group therapy sessions at the mental health clinic. Today his mother calls the clinic nurse to report that her son became angry last night and put his fist through a window. Which intervention is most important for the nurse to implement?
- A. Advise the mother to call the police if violent behavior occurs again.
- B. Refer the mother for psychiatric evaluation for anxiety and depression.
- C. Reinforce the need for the adolescent to attend group therapy sessions.
- D. Tell the mother to describe her feelings of helplessness to her son.
Correct Answer: A
Rationale: Advising the mother to call the police if violent behavior occurs again addresses the safety of the client and others, ensuring appropriate intervention.
A client diagnosed with schizophrenia has been receiving haloperidol for the past year, and the treatment plan includes moving the client to a lower maintenance dosage. Which intervention should the nurse include in this client's plan of care? (Select all that apply)
- A. Shielding the client from direct sunlight when outdoors.
- B. Gradually withdrawing the medication over several days.
- C. Enforcing a fluid restriction during dosage adjustment.
- D. Increasing the dosage if the white blood cell count drops.
Correct Answer: A,B
Rationale: Shielding from sunlight prevents sunburn due to haloperidol's photosensitivity, and gradual withdrawal avoids symptom worsening.
A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client's rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?
- A. Disrupts group activities.
- B. Wanders into client's rooms.
- C. Talks with nonsensical words.
- D. Refuses antipsychotic medications.
Correct Answer: B
Rationale: Wandering into client's rooms poses a safety risk to both the client and others, indicating a need for constant observation to prevent potential harm.
A client with opioid dependence makes a statement to the nurse about desiring to lead a healthier lifestyle by making changes in the next 2 weeks. How should the nurse respond?
- A. Support the client to list small behavioral changes needed.
- B. Explain the specific skills needed to prevent a relapse.
- C. Provide teaching on the symptoms of substance use dependence.
- D. Advise the client to reschedule until committing to recovery.
Correct Answer: A
Rationale: Supporting the client to list small behavioral changes is a person-centered approach that promotes achievable progress toward a healthier lifestyle.