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The RN is leading a group on the inpatient psychiatric unit. Which approach should the RN use during the working phase of group development?
- A. Establishing a rapport with group members.
- B. Clarifying the nurse’s role and clients’ responsibilities.
- C. Discussing ways to use new coping skills learned.
- D. Helping clients identify areas of problem in their lives.
Correct Answer: C
Rationale: The correct answer is C: Discussing ways to use new coping skills learned. During the working phase of group development, the focus is on implementing and practicing new skills and strategies. This helps group members apply what they have learned to their real-life situations. By discussing ways to use new coping skills, the RN is facilitating the group's progress towards achieving their therapeutic goals.
A: Establishing a rapport with group members is important in the initial phase of group development, not during the working phase.
B: Clarifying the nurse’s role and clients’ responsibilities is more relevant to the orientation phase, not the working phase.
D: Helping clients identify areas of problem in their lives is typically done in the initial assessment phase, not during the working phase.
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Which student behavior is consistent with therapeutic communication?
- A. Offering your opinion when asked to convey support.
- B. Summarizing the essence of the patient’s comments in your own words.
- C. Interrupting periods of silence before they become awkward for the patient.
- D. Telling the patient he did well when you approve of his statements or actions.
Correct Answer: B
Rationale: The correct answer is B: Summarizing the essence of the patient's comments in your own words. This behavior is consistent with therapeutic communication as it shows active listening and understanding of the patient's feelings and thoughts. By summarizing, the healthcare provider demonstrates empathy and helps clarify any misunderstandings.
A: Offering your opinion when asked to convey support may not always align with therapeutic communication, as it can shift the focus from the patient to the provider's perspective.
C: Interrupting periods of silence before they become awkward for the patient can disrupt the patient's thought process and hinder open communication.
D: Telling the patient he did well when you approve of his statements or actions may come across as judgmental and can limit the patient's ability to express themselves fully.
A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN?
- A. Is attempting the physically restrain the patient.
- B. Remains at a distance of 4 feet from the client.
- C. Tells the client to go to the quiet area of the unit.
- D. Is using a loud voice to talk to the client.
Correct Answer: A
Rationale: The correct answer is A because attempting to physically restrain a client with escalating aggressive behavior can escalate the situation further, leading to potential harm to both the client and the mental health worker. Physical restraint should only be used as a last resort and under the guidance of a registered nurse to ensure safety and prevent harm. Choices B, C, and D are not immediate interventions for managing escalating aggressive behavior. Remaining at a distance of 4 feet, telling the client to go to a quiet area, or using a loud voice are not effective strategies to de-escalate the situation and may not address the root cause of the aggression.
An RN is providing education to the family of a client diagnosed with schizophrenia who is being treated with clozapine (Clozaril). The RN should instruct the family to report which symptom immediately?
- A. Sore throat
- B. Weight loss
- C. Constipation
- D. Lightheadedness
Correct Answer: A
Rationale: The correct answer is A: Sore throat. Clozapine can cause agranulocytosis, a potentially life-threatening condition characterized by a decrease in white blood cells. Sore throat could indicate an infection, necessitating immediate medical attention to monitor for agranulocytosis. Weight loss (B) and constipation (C) are common side effects of clozapine but do not require immediate reporting. Lightheadedness (D) may be a side effect but not as urgent as a sore throat in this case.
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 thorough explanations when cleansing wound.
- B. Perform the dressing change in a non-judgmental manner.
- C. Ask in a non-threatening manner why the client cut own abdomen.
- D. Request another staff member assist with the dressing change.
Correct Answer: B
Rationale: The correct answer is B: Perform the dressing change in a non-judgmental manner. When caring for a client with borderline personality disorder who has self-inflicted injuries, it is crucial to approach the situation with empathy and without passing judgment. This approach helps build trust, maintains the therapeutic relationship, and encourages open communication. Providing detailed explanations (choice A) may overwhelm the client. Asking about the self-inflicted behavior (choice C) in a non-threatening manner can be appropriate but should not be the primary focus during the dressing change. Requesting another staff member's assistance (choice D) may not be necessary if the RN can handle the situation effectively.
A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?
- A. Place in a side-lying position with head of bed elevated.
- B. Administer disulfiram (Antabuse) immediately
- C. Give lorazepam (Ativan) PRN for signs of withdrawal.
- D. Provide thiamine and folate supplements as prescribed.
Correct Answer: A
Rationale: The correct answer is A: Place in a side-lying position with head of bed elevated. This is the priority intervention because the client is difficult to arouse, indicating potential risk for airway compromise and aspiration due to the head injury and elevated BAL. Placing the client in a side-lying position with the head of the bed elevated helps prevent aspiration and promotes optimal airway management. Administering disulfiram (choice B) is not indicated as the priority intervention in this acute situation. Giving lorazepam (choice C) for signs of withdrawal may further depress the client's level of consciousness and is not the priority at this time. Providing thiamine and folate supplements (choice D) is important for alcohol-related deficiencies but does not address the immediate risk of airway compromise.