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The nurse plans to use role-playing as a therapeutic measure. Which individual is most likely to benefit from this type of therapeutic intervention?
- A. An adult with schizophrenia who often refuses to take prescribed antipsychotic medications.
- B. A hyperactive 4-year-old who has recently been tested for autism.
- C. An older adult resident of a long-term care facility who sometimes takes other residents' belongings.
- D. An adolescent who is depressed over not being accepted by peers.
Correct Answer: D
Rationale: Role-playing helps adolescents practice social skills and coping strategies for peer rejection, making it most effective for this group.
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Which intervention(s) should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)
- A. Restrict visitors to family members only.
- B. Discuss the client's suicide plan.
- C. Limit time allowed to play video games.
- D. Encourage the client to discuss thoughts and feelings about wanting to die.
- E. Reinforce statements regarding a will to live and realistic plans for the future.
Correct Answer: B,D,E
Rationale: Discussing suicide plans, encouraging expression of suicidal thoughts, and reinforcing hope are critical for safety and therapeutic support. Restricting visitors or limiting video games are less relevant.
A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?
- A. Assist the client with relaxation techniques in the group.
- B. Escort the client from the group to reduce stimuli.
- C. Provide education about ways to cope with anxiety.
- D. Ask the client to describe and identify the source of the feelings.
Correct Answer: A
Rationale: Assisting with relaxation techniques in the group provides immediate anxiety relief and support, suitable for acute anxiety.
When responding to a call light, the nurse finds a client with aggressive behaviors pacing, and restless in the room. The client shouts, 'What took you so long to get in here!' Which action should the nurse implement?
- A. Request backup from the staff.
- B. Stand in the doorway.
- C. Provide for personal space.
- D. Encourage the client to sit down.
Correct Answer: C
Rationale: Providing personal space reduces the perception of threat, helping de-escalate agitation safely.
A young adult client with a recent diagnosis of bipolar disorder takes lithium carbonate daily. The client informed the school nurse of the desire to live away from home to attend college after graduating in one month. Which information is most important for the nurse to provide the client and his family?
- A. The client should be aware of the signs and symptoms of his illness.
- B. The client should plan to participate in group or individual therapy while at college.
- C. Despite the illness, the client should be able to live away from home.
- D. The client's serum lithium levels should be routinely evaluated.
Correct Answer: D
Rationale: Routine monitoring of serum lithium levels is crucial to ensure therapeutic levels and prevent lithium toxicity, especially critical for a newly diagnosed client transitioning to college.
A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?
- A. I just feel like my life is filled with emptiness.'
- B. I have three firearms locked in a safe at home.'
- C. My daughter is the only reason I keep trying.'
- D. My panic attacks happen once every month.'
Correct Answer: B
Rationale: Access to firearms is a significant risk factor for suicide, making it critical to document. Other comments are relevant but less urgent.