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The nurse observes a client sitting alone at a table, looking sad and preoccupied. The nurse sits down and says, 'I saw you sitting alone and thought I might keep you company.' The client turns away from the nurse. Which would be the most therapeutic nursing intervention?
- A. Move to another chair closer to the client and say, 'The staff is here to help you.'
- B. Move to a chair a little further away and say, 'We can just sit together quietly.'
- C. Remain in place and say, 'How are you feeling today?'
- D. Say, 'I'll visit with you a little later,' and leave the client alone for a while.
Correct Answer: B
Rationale: Offering quiet companionship while respecting personal space conveys acceptance and supports the depressed client.
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A client with mania is in the dining room at lunchtime and is observed taking food from other clients' trays. The nurse's intervention should be based on which rationale?
- A. As soon as lunch is over, the client will calm down.
- B. Other clients need to be protected from the intrusive behavior.
- C. The client's behavior is not an imminent threat to anyone's physical safety.
- D. The client needs food and fluids in any way possible.
Correct Answer: B
Rationale: Protecting other clients from intrusive behavior upholds their rights and maintains a safe environment.
The nurse is planning care for a client with major depression. Which is an appropriate expected outcome?
- A. The client will avoid causing harm to others.
- B. The client will be free from stress.
- C. The client will independently carry out activities of daily living.
- D. The client will not experience agitation.
Correct Answer: C
Rationale: Independently performing activities of daily living is a realistic and appropriate outcome for a client with depression.
A client who just went through an upsetting divorce is threatening to commit suicide with a handgun. The client is involuntarily admitted to the psychiatric unit. Which nursing diagnosis has the highest priority?
- A. Hopelessness related to recent divorce.
- B. Ineffective coping related to inadequate stress management.
- C. Spiritual distress related to conflicting thoughts about suicide and sin.
- D. Risk for suicide related to a highly lethal plan.
Correct Answer: D
Rationale: The risk for suicide with a lethal plan is the highest priority, as safety is paramount in this situation.
A client with bipolar disorder is admitted to the psychiatric unit. The client is talking loudly, walking back and forth rapidly, and exhibiting a short attention span. Which nursing intervention should occur first?
- A. Decrease the client's environmental stimuli.
- B. Give the client feedback about his behavior.
- C. Introduce the client to other staff on the unit.
- D. Tell the client about hospital rules and policies.
Correct Answer: A
Rationale: Reducing environmental stimuli is the priority to help calm an agitated client with bipolar disorder.
A client who has been discharged home on Celexa (citalopram) calls the nurse complaining that the medication causes her to feel too drowsy. The nurse should make which of the following suggestions?
- A. Make an appointment to change to a different medication.
- B. Take the medication at night.
- C. Be patient while this early side effect subsides.
- D. Skip a dose if drowsiness is excessive.
Correct Answer: B
Rationale: Taking citalopram at night minimizes daytime drowsiness, a common side effect, improving adherence.