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What intervention is best for the nurse to implement for a male client with schizophrenia who is demonstrating echolalia, which is becoming annoying to other clients on the unit?
- A. Avoid recognizing the behavior.
- B. Isolate the client from other clients.
- C. Administer a PRN sedative.
- D. Escort the client to his room.
Correct Answer: D
Rationale: Echolalia, the constant repetition of what others are saying, can be disruptive to the therapeutic environment. The most appropriate intervention is to escort the client to his room. This action provides the client with a private space where he can engage in the behavior without disturbing other clients. Avoiding recognition of the behavior (Choice A) may not address the issue and could lead to increased annoyance among other clients. Isolating the client (Choice B) may have negative psychological effects and should be avoided unless absolutely necessary for safety concerns. Administering a PRN sedative (Choice C) should be considered only as a last resort and if other de-escalation techniques have been unsuccessful.
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The healthcare provider is assessing a client who has been taking an antidepressant for several months. Which symptom would suggest that the medication is working?
- A. Improved mood and increased energy.
- B. Increased appetite and weight gain.
- C. Decreased anxiety and agitation.
- D. Enhanced sleep patterns and vivid dreams.
Correct Answer: A
Rationale: When assessing the effectiveness of an antidepressant, improved mood and increased energy are positive indicators that the medication is working. Choice B, increased appetite and weight gain, is more commonly associated with side effects of some antidepressants, such as certain tricyclic antidepressants. Choice C, decreased anxiety and agitation, could be related to the therapeutic effects of antidepressants in treating anxiety disorders but may not specifically indicate the efficacy of the medication for depression. Choice D, enhanced sleep patterns and vivid dreams, while changes in sleep patterns can be influenced by antidepressants, they are not the primary indicators of antidepressant efficacy. Therefore, the correct choice is A as it directly reflects the desired outcomes of antidepressant therapy.
A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determines that the client is homeless and slightly suspicious. This client's treatment plan should include what priority problem?
- A. Self-care deficit.
- B. Disturbed sensory perception.
- C. Ineffective community coping.
- D. Acute confusion.
Correct Answer: D
Rationale: The correct answer is 'D: Acute confusion.' In the given scenario, the client is disoriented, disorganized, and confused, indicating acute confusion. This is a priority issue to address for immediate safety and appropriate care. Option A, self-care deficit, is not the priority as the client's safety and mental status take precedence. Option B, disturbed sensory perception, does not align with the client's presentation of confusion. Option C, ineffective community coping, is not the immediate concern as the client's cognitive state needs urgent attention.
A male client approaches the RN with an angry expression on his face and raises his voice, saying, "My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!" The RN recognizes that the client is using which defense mechanism?
- A. Denial.
- B. Projection.
- C. Rationalization.
- D. Splitting.
Correct Answer: B
Rationale: The correct answer is B: Projection. Projection involves attributing one's own unacceptable feelings or thoughts to others, as seen in the client's accusations of his roommate's behavior. In this scenario, the client is projecting his own anger and potential for violence onto his roommate. Choice A, Denial, involves refusing to acknowledge some aspect of reality. Choice C, Rationalization, is a defense mechanism where logical reasons are given to justify behaviors that are actually based on unacceptable motives. Choice D, Splitting, is a defense mechanism where a person sees others as all good or all bad, not applicable in this case.
A client with alcohol use disorder is being treated in a rehabilitation facility. Which behavior indicates that the client is making progress in recovery?
- A. Attends all scheduled therapy sessions regularly.
- B. Is participating in group therapy and sharing experiences.
- C. Completes a work-study program.
- D. Has a decreased need for psychiatric medication.
Correct Answer: B
Rationale: The correct answer is B. Participation in group therapy and sharing experiences is a positive sign of progress in recovery for a client with alcohol use disorder. It fosters peer support, allows for personal insight, and encourages social interaction, which are essential aspects of the recovery process. Choice A, attending all scheduled therapy sessions regularly, is important but may not necessarily indicate the same level of progress as active participation in group therapy. Choice C, completing a work-study program, is not directly related to the client's recovery from alcohol use disorder. Choice D, having a decreased need for psychiatric medication, is not necessarily a reliable indicator of progress in recovery from alcohol use disorder, as medication management is a separate aspect of treatment.
The client is being educated by the healthcare provider about starting a prescribed abstinence therapy with disulfiram (Antabuse). What information should the client understand?
- A. Maintain complete abstinence from heroin or cocaine use.
- B. Stay alcohol-free for at least 12 hours before the first dose.
- C. Participate in monthly Alcoholics Anonymous meetings.
- D. Disclose to others that he is a substance abuser.
Correct Answer: B
Rationale: The correct answer is B. Before starting disulfiram therapy (Antabuse), the client must comprehend the need to remain alcohol-free for a minimum of 12 hours. This is crucial to prevent the unpleasant and potentially dangerous reactions that can occur with concurrent alcohol consumption while on disulfiram. Choices A, C, and D are incorrect because they do not directly relate to the specific requirement for alcohol abstinence before initiating disulfiram therapy.