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The nurse observes a client who is admitted to the mental health unit and identifies that the client is talking continuously, using words that rhyme but that have no context or relationship with one topic to the next in the conversation. This client's behavior and thought processes are consistent with which syndrome?
- A. Dementia
- B. Depression
- C. Schizophrenia
- D. Chronic brain syndrome
Correct Answer: C
Rationale: The client is demonstrating symptoms of schizophrenia, such as disorganized speech that may include word salad (a type of communication that mixes real and imaginary words in no logical order), incoherent speech, and clanging (rhyming). Dementia (Choice A) is characterized by memory loss and cognitive decline, not by disorganized speech. Depression (Choice B) typically presents with persistent feelings of sadness and loss of interest, not disorganized speech. Chronic brain syndrome (Choice D) is a vague term and does not specifically describe the symptoms mentioned in the scenario.
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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.
In the described scenario, a manic client threatens a nurse with physical violence after being told they cannot have a stripper perform. What is the most appropriate action for the LPN/LVN to take?
- A. Orient the client to time, person, and place
- B. Tell the client that the behavior is inappropriate
- C. Escort the manic client to her room, with assistance
- D. Tell the client that smoking privileges are revoked for 24 hours
Correct Answer: C
Rationale: In this situation, where the manic client becomes verbally abusive and threatens physical violence, the most appropriate action for the LPN/LVN is to escort the client to her room with assistance. This action helps ensure the safety of both the client and the nurse, while also providing a controlled environment that can help de-escalate the situation. Choices A and B do not address the immediate safety concerns presented by the client's behavior. Choice D, revoking smoking privileges, is not directly related to the client's current behavior and does not address the threat of violence.
The RN is providing care for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the RN use when changing this client's dressing?
- A. Provide detailed explanations during wound cleansing.
- B. Perform the dressing change in a non-judgmental manner.
- C. Ask the client non-threateningly why they cut their abdomen.
- D. Request assistance from another staff member for the dressing change.
Correct Answer: B
Rationale: Performing the dressing change in a non-judgmental manner is crucial when caring for a client with borderline personality disorder who has self-inflicted injuries. This approach helps build trust, reduces feelings of shame or guilt, and fosters a therapeutic relationship. Choice A is incorrect because while detailed explanations may be necessary, the focus should be on the non-judgmental approach. Choice C is inappropriate as it may come across as accusatory or threatening, potentially worsening the client's emotional state. Choice D is not the best option as the RN should strive to handle the situation themselves in a supportive and empathetic manner.
A nurse is caring for a client with depression who is prescribed fluoxetine (Prozac). The client reports difficulty sleeping. What is the most appropriate nursing intervention?
- A. Encourage the client to take short naps during the day.
- B. Suggest the client drink a warm beverage before bedtime.
- C. Recommend the client exercise immediately before bedtime.
- D. Advise the client to take a sleep aid nightly.
Correct Answer: B
Rationale: The most appropriate nursing intervention for a client with difficulty sleeping due to depression and prescribed fluoxetine is to suggest the client drink a warm beverage before bedtime. This intervention can promote relaxation and help establish a bedtime routine, potentially improving sleep quality. Encouraging short naps during the day (Choice A) may disrupt the client's nighttime sleep schedule. Recommending exercise immediately before bedtime (Choice C) can have a stimulating effect, making it harder for the client to fall asleep. Advising the client to take a sleep aid nightly (Choice D) should only be done under the guidance of a healthcare provider due to potential interactions with fluoxetine.
A client with anorexia nervosa is being treated in an inpatient unit. Which intervention is a priority for the nurse?
- A. Encourage the client to exercise to build muscle mass.
- B. Provide liquid supplements between meals.
- C. Allow the client to choose their own meals.
- D. Monitor the client's weight daily.
Correct Answer: D
Rationale: Monitoring the client's weight daily is a priority intervention for a nurse caring for a client with anorexia nervosa. Weight monitoring is crucial in assessing the client's progress and adjusting treatment as necessary to prevent complications such as refeeding syndrome, electrolyte imbalances, and cardiac issues. Encouraging exercise (Choice A) can exacerbate the client's unhealthy relationship with food and body image. Providing liquid supplements (Choice B) is important but may not be the priority over monitoring weight. Allowing the client to choose their own meals (Choice C) may not be suitable initially as they may make unhealthy choices or avoid meals altogether.