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Two days after his last drink, a male alcoholic client becomes agitated and yells at his wife and children, 'Stay away from me!' His vital signs are elevated. What nursing diagnosis has the highest priority?
- A. High risk for social isolation.
- B. Altered parenting.
- C. Ineffective individual coping.
- D. High risk for injury.
Correct Answer: D
Rationale: The correct answer is 'High risk for injury.' The client's agitation, elevated vital signs, and aggressive behavior pose a threat to himself and his family. Addressing the risk for injury is the priority to ensure the safety of all individuals involved. Choices A, B, and C are not the highest priority in this scenario. 'High risk for social isolation' does not address the immediate physical safety concern. 'Altered parenting' and 'Ineffective individual coping' are important but not as urgent as the risk for injury in this situation.
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A nurse notes that a depressed female client has been more withdrawn and less communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?
- A. Engage the client in non-threatening conversations.
- B. Schedule a daily conference with the social worker.
- C. Encourage the client's family to visit more often.
- D. Encourage the client to participate in group activities.
Correct Answer: D
Rationale: The correct answer is to encourage the client to participate in group activities. Group activities can help improve social interaction and potentially reduce feelings of isolation in depressed clients. Choice A, engaging the client in non-threatening conversations, may be helpful but may not address the underlying need for social interaction that group activities can provide. Scheduling a daily conference with the social worker (Choice B) may not directly address the client's need for social engagement. Encouraging the client's family to visit more often (Choice C) is important for support but may not provide the same level of social interaction as group activities.
A client with major depressive disorder is being treated with cognitive-behavioral therapy (CBT). Which client statement indicates that CBT is having a positive effect?
- A. "I understand now that my negative thoughts are not always true."
- B. "I still feel down, but I am able to go to work."
- C. "I have stopped taking my antidepressant medication."
- D. "I avoid situations that make me feel anxious."
Correct Answer: A
Rationale: The correct answer is A. Recognizing and challenging negative thoughts is a fundamental aspect of cognitive-behavioral therapy (CBT). In this statement, the client demonstrates insight into the fact that their negative thoughts may not always be accurate, showing progress in reframing their thoughts. Choice B indicates some improvement in functioning but does not directly relate to the core principles of CBT. Choice C is concerning as abruptly stopping antidepressant medication can be detrimental to the client's well-being. Choice D reflects avoidance behavior, which is typically a target for intervention in CBT rather than a sign of positive progress.
During discharge planning for a male client with schizophrenia who insists on returning to his apartment despite being informed to move to a boarding home, what is the most important nursing diagnosis?
- A. Ineffective denial related to situational anxiety.
- B. Ineffective coping related to inadequate support.
- C. Social isolation related to difficult interactions.
- D. Self-care deficit related to cognitive impairment.
Correct Answer: A
Rationale: The most important nursing diagnosis for discharge planning in this scenario is 'Ineffective denial related to situational anxiety.' The client's insistence on returning to his apartment despite being informed otherwise indicates a form of denial, possibly due to anxiety about the situational change. Focused discharge planning should address this denial and the underlying anxiety to ensure a smooth transition. Choices B, C, and D are not as relevant in this context as the primary issue lies in the client's denial and anxiety regarding the change in living arrangements, rather than coping, social interactions, or self-care deficits.
At the first meeting of a group of older adults at a daycare center for the elderly, the nurse asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, 'You tell me, you're the leader.' What is the best response for the nurse to make?
- A. 'Yes, I am the leader today. Would you like to be the leader tomorrow?'
- B. 'Yes, I will be leading this group. What would you like to accomplish during this time?'
- C. 'Yes, I have been assigned to be the leader of this group. I will be here for the next six weeks.'
- D. 'Yes, I am the leader. You seem angry about not being the leader yourself.'
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with bipolar disorder is admitted to the psychiatric unit in a manic state. What is the most therapeutic nursing intervention?
- A. Allow the client to engage in any activity they choose.
- B. Provide a structured environment with reduced stimuli.
- C. Encourage the client to express their thoughts freely.
- D. Place the client in a room with another client for socialization.
Correct Answer: B
Rationale: During a manic state, individuals with bipolar disorder may exhibit hyperactivity, impulsivity, and reduced need for sleep. Providing a structured environment with reduced stimuli is the most therapeutic nursing intervention as it can help manage the client's excessive energy and prevent overstimulation. Choice A is incorrect as allowing the client to engage in any activity they choose may exacerbate their symptoms or lead to risky behaviors. Choice C, encouraging the client to express their thoughts freely, may not be appropriate during a manic state as it can further escalate their racing thoughts. Choice D, placing the client in a room with another client for socialization, may not be beneficial during a manic episode as it could increase stimulation and potentially lead to agitation.