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The RN on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the RN implement the evening before the scheduled ECT?
- A. Hold all bedtime medications.
- B. Keep the client NPO after mid-night.
- C. Implement elopement precautions.
- D. Give the client an enema at bedtime.
Correct Answer: B
Rationale: The correct answer is B: Keep the client NPO after midnight. This is important to prevent aspiration during ECT, as anesthesia is often used and the client must have an empty stomach. Holding all bedtime medications (choice A) is not necessary unless specified by the healthcare provider. Implementing elopement precautions (choice C) is not relevant to ECT procedure. Giving the client an enema at bedtime (choice D) is unnecessary and not indicated for ECT preparation.
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A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to verbally attack other clients. What intervention is most appropriate for the RN to use to manage the client’s behavior?
- A. Assist the client to a safe area to avoid injury.
- B. Establish clear and firm limits with the client.
- C. Offer medication to help calm the client down.
- D. Speak with the client in a calm, non-threatening manner.
Correct Answer: A
Rationale: The correct answer is A: Assist the client to a safe area to avoid injury. This intervention is most appropriate because the client is engaging in potentially harmful behaviors such as vigorous physical activity and verbal aggression. By moving the client to a safe area, the nurse can prevent the client from causing harm to themselves or others. It is essential to prioritize physical safety in situations like this.
Option B, establishing clear and firm limits, may not be effective in the moment when the client is in an agitated state and may not respond well to verbal directives. Option C, offering medication, should not be the first response as it may not address the immediate safety concerns. Option D, speaking calmly, may not be enough to de-escalate the situation when the client is in a heightened state of agitation.
Overall, ensuring the physical safety of the client and others is the priority in this scenario, making option A the most appropriate intervention.
April, a 10-year-old admitted to inpatient pediatric care, has been getting more and more wound up and is losing self-control in the day room. Time-out does not appear to be an effective tool for April to engage in self-reflection. April’s mother admits to putting her in time-out up to 20 times a day. The nurse recognizes that:
- A. Time-out is an important part of April’s baseline discipline.
- B. Time-out is no longer an effective therapeutic measure.
- C. April enjoys time-out, and acts out to get some alone time.
- D. Time-out will need to be replaced with seclusion and restraint.
Correct Answer: B
Rationale: The correct answer is B: Time-out is no longer an effective therapeutic measure. In this scenario, April's escalating behavior and the ineffectiveness of time-out suggest that it is not addressing the underlying issues causing her behavior. Continuous use of time-out can lead to it losing its effectiveness and may not promote self-reflection. April's behavior worsening despite frequent use of time-out indicates the need for a different approach to address her needs.
Choices A, C, and D are incorrect because they do not address the situation at hand. Choice A assumes time-out is still effective despite evidence to the contrary. Choice C assumes April enjoys time-out, which is not supported by the information given. Choice D suggests a drastic and inappropriate measure of seclusion and restraint, which should only be used as a last resort in emergency situations.
A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What is the priority nursing problem for admission to the psychiatric unit?
- A. Ineffective sexual patterns.
- B. Impaired environmental interpretation.
- C. Disturbed sensory perception.
- D. Compromised family coping.
Correct Answer: C
Rationale: The correct answer is C: Disturbed sensory perception. The client's delusions and false beliefs indicate a break from reality, which is a hallmark symptom of disturbed sensory perception. This poses a risk to the client's safety and well-being. Ineffective sexual patterns (choice A) and compromised family coping (choice D) may be secondary to the primary issue of distorted perceptions. Impaired environmental interpretation (choice B) is less relevant as the client's issues are more internal. Overall, addressing the disturbed sensory perception is the priority to ensure the client's safety and initiate appropriate treatment.
A client with obsessive-compulsive disorder (OCD) repeatedly checks to see if the door is locked and asks for reassurance that it is locked. What is the most appropriate intervention by the RN to address this behavior?
- A. Set a specific limit on the number of times the client can check the door.
- B. Help the client find an alternative activity to perform.
- C. Provide consistent reassurance that the door is locked.
- D. Ignore the checking behavior and focus on other behaviors.
Correct Answer: A
Rationale: The correct answer is A: Set a specific limit on the number of times the client can check the door. This intervention helps establish boundaries and structure for the client, which can assist in reducing compulsive behaviors. By setting a specific limit, the client is encouraged to gradually decrease the checking behavior and learn to cope with the anxiety associated with uncertainty. This approach promotes independence and empowerment for the client.
Choice B is incorrect because finding an alternative activity does not directly address the obsessive checking behavior. Choice C is incorrect as providing consistent reassurance reinforces the compulsive behavior. Choice D is incorrect because ignoring the behavior does not actively address or help decrease the compulsive checking.
A female patient diagnosed with schizophrenia has been prescribed a first-generation antipsychotic medication. What information should the nurse provide to the patient regarding her signs and symptoms?
- A. Her memory problems will likely decrease.
- B. Depressive episodes should be less severe.
- C. She will probably enjoy social interactions more.
- D. She should experience a reduction in hallucinations.
Correct Answer: D
Rationale: The correct answer is D: She should experience a reduction in hallucinations. First-generation antipsychotic medications are primarily used to target positive symptoms of schizophrenia, such as hallucinations. These medications work by blocking dopamine receptors in the brain, which can help reduce hallucinations. Providing this information to the patient is crucial for managing expectations and understanding the potential benefits of the prescribed medication.
Choices A, B, and C are incorrect because first-generation antipsychotics do not specifically address memory problems, depressive episodes, or social interactions. While some side effects of the medication may impact these areas, the primary focus is on reducing hallucinations and other positive symptoms of schizophrenia. It is important for the nurse to provide accurate information to the patient to ensure effective treatment and management of their condition.