Nokea
The nurse provides care for a client diagnosed with paranoid schizophrenia. The client’s spouse states that the client has not slept in 3 nights. Which action by the nurse is most appropriate?
- A. Assign the client to straighten up the day room.
- B. Establish a trusting nurse-client relationship.
- C. Encourage the client to sleep and offer a sleep aid.
- D. Introduce the client to other clients on the unit.
Correct Answer: C
Rationale: Encouraging sleep and offering a sleep aid addresses the client’s insomnia, which can exacerbate paranoia and schizophrenia symptoms. A trusting relationship is important but less urgent, and other options do not address the immediate need for rest.
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A 12-year-old client is seen in the health care clinic. During the assessment, which finding would suggest to the nurse that the client is experiencing a disruption in the development of self-concept?
- A. The child has many friends.
- B. The child has a part-time babysitting job.
- C. The child has an intimate relationship with a significant other.
- D. The child enjoys playing chess and mastering new skills with this game.
Correct Answer: C
Rationale: The formation of an intimate relationship would not be expected until young adulthood. Friends are important and appropriate for members of this age group. A sense of industry is appropriate for this age group, and it may be exhibited by the child having a part-time job. The increase in self-esteem associated with skill mastery is an important part of development for the school-age child.
The nurse is developed a teaching plan for a client prescribed spironolactone. On which psychosocial side effect of the medication should the nurse base the teaching plan?
- A. Edema
- B. Hair loss
- C. Weight loss
- D. Decreased libido
Correct Answer: D
Rationale: The nurse should be aware of the fact that the client taking spironolactone, a potassium-sparing diuretic, may experience body image changes that result from a threatened sexual identity. These are related to decreased libido, gynecomastia in males, and hirsutism in females. Edema, weight loss, and hair loss are not specifically associated with the use of this medication.
The nurse is planning care for a client with an intrauterine fetal demise. Which are appropriate goals for this client?
- A. The woman's grieving process will be limited to 6 months.
- B. The woman and her family will discuss plans for going home without the infant.
- C. The woman and her family will express their grief about the loss of their desired infant.
- D. The woman will recognize that thoughts of worthlessness and suicide are normal after a loss.
- E. The woman and her family will contact their pastor or grief counselor for support after discharge.
Correct Answer: B,C,E
Rationale: It is important for the nurse to assess whether the client is undergoing the normal grieving process. Options 2, 3, and 5 are appropriate goals. Signs that are causes for concern and that are not part of the normal grieving process include thoughts of worthlessness and suicide and limiting the grieving process to a short amount of time.
The nurse conducts a grief support group at the community mental health center. Which client will the nurse identify as needing additional assistance before participating in this group?
- A. Older adult male whose estranged spouse, living in another state, died from heart disease 3 months ago.
- B. Older adult female whose spouse died 3 years ago in a car accident.
- C. Middle-aged female who started drinking after the sudden death of the spouse 6 months ago.
- D. Young male with two children whose spouse died 1 year ago due to breast cancer.
Correct Answer: C
Rationale: The middle-aged female who began drinking after her spouse’s death indicates unhealthy coping and potential substance abuse, requiring individual intervention before group participation. Other clients show grief but no immediate maladaptive behaviors.
A client who is experiencing suicidal thoughts shares with the nurse that, 'I was awake most of the night. It just doesn't seem worth it anymore. Why not just end it all?' Which response should the nurse make to best further assess the client?
- A. Did you sleep at all last night?
- B. Tell me what you mean by that.
- C. I know you have had a stressful night.
- D. I'm sure that your family is worried about you.
Correct Answer: B
Rationale: Option 2 allows the client the opportunity to tell the nurse more about what his or her current thoughts are. Option 1 changes the subject and may block communication. Although option 3 offers empathy to the client, it does not further assess the client. Option 4 is false reassurance and may block communication.