Nokea
The nurse on the day shift receives report about a client with depression who was found on the floor in the morning. What intervention is best for the nurse to implement?
- A. Assist the client to get out of bed and involved in an activity.
- B. Monitor the client's appetite and sleep patterns.
- C. Assess the client's feelings regarding the hospital stay.
- D. Explain that staff will check on the client every 30 minutes.
Correct Answer: A
Rationale: Assisting the client to engage in activities is the best intervention as it can help improve mood and prevent further decline in function. Option B, monitoring appetite and sleep patterns, is important but not the most immediate intervention needed in this situation. Option C, assessing feelings about the hospital stay, is also important but addressing the client's physical safety and well-being should take precedence. Option D, explaining the frequency of staff checks, is not as effective in addressing the client's immediate needs for engagement and support.
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The nurse is assessing a client who has schizophrenia and is exhibiting symptoms of paranoia. Which behavior would the nurse most likely observe?
- A. The client is seen as unmotivated and withdrawn.
- B. The client is preoccupied with a fear of being harmed.
- C. The client displays a blunted affect and lacks emotional response.
- D. The client avoids group activities and shows decreased appetite.
Correct Answer: B
Rationale: In clients with paranoia, they typically exhibit an intense fear of being harmed, persecuted, or targeted by others. This fear often dominates their thoughts and can significantly impact their daily functioning and interactions. Choice A, being unmotivated and withdrawn, is more indicative of negative symptoms of schizophrenia, such as avolition and social withdrawal. Choice C, displaying a blunted affect and lacking emotional response, is associated with flat affect, a symptom commonly seen in schizophrenia but not specific to paranoia. Choice D, avoiding group activities and showing decreased appetite, may be related to various symptoms or side effects, but it is not a defining characteristic of paranoia in schizophrenia.
The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (SOA)
- A. Purchase a gun for protection.
- B. Establish a code with family and friends to signal violence.
- C. Take a self-defense course focused on protecting oneself.
- D. Prepare a bag with extra clothes for self and children.
Correct Answer: B
Rationale: B: Establishing a code with family and friends is important as it helps discreetly communicate the need for help without alerting the abuser. D: Having a bag prepared with essentials ensures the victim can swiftly leave if required. A: Purchasing a gun can escalate violence and is not a recommended safety strategy. C: Taking a self-defense course focused on protecting oneself is beneficial, but courses that involve retaliation are not recommended as they can increase risk and escalate violence.
Which client statement suggests to the nurse that the client is using the defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit?
- A. I am here because the police thought I was doing something wrong
- B. At least I hit the wall instead of hitting the psychiatric aide
- C. I want to be here because I know it is the best psychiatric facility
- D. Don't believe everything my family tells you, I am not crazy
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determines that the client is homeless and slightly suspicious. This client's treatment plan should include what priority problem?
- A. Self-care deficit.
- B. Disturbed sensory perception.
- C. Ineffective community coping.
- D. Acute confusion.
Correct Answer: D
Rationale: The correct answer is 'D: Acute confusion.' In the given scenario, the client is disoriented, disorganized, and confused, indicating acute confusion. This is a priority issue to address for immediate safety and appropriate care. Option A, self-care deficit, is not the priority as the client's safety and mental status take precedence. Option B, disturbed sensory perception, does not align with the client's presentation of confusion. Option C, ineffective community coping, is not the immediate concern as the client's cognitive state needs urgent attention.
A male client comes to the emergency center with an erection that will not resolve. The client reports that he is taking trazodone (Desyrel) for insomnia. Which information is most important for the nurse to ask this client?
- A. Have you taken any medication for erectile dysfunction?
- B. Are you experiencing any other sexual dysfunctions or problems?
- C. When was the last time you consumed an alcoholic beverage?
- D. Do you have a history of angina or high blood pressure?
Correct Answer: B
Rationale: In this scenario, the most important question for the nurse to ask the client is whether he is experiencing any other sexual dysfunctions or problems. This inquiry is crucial as it can help in determining if the persistent erection is a side effect of trazodone. Asking about medication for erectile dysfunction (Choice A) may not provide relevant information in this case, as the focus is on the potential side effects of trazodone. Inquiring about the last time the client consumed alcohol (Choice C) is not directly related to the situation at hand. Questioning about a history of angina or high blood pressure (Choice D) is important for overall assessment but is not as directly relevant to the immediate concern of the persistent erection potentially caused by trazodone.