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What intervention is likely to be most effective in returning a middle-aged adult with major depressive disorder who suffers from psychomotor retardation, hypersomnia, and amotivation to a normal level of functioning?
- A. Encourage the client to exercise.
- B. Suggest that the client develop a list of pleasurable activities.
- C. Provide education on methods to enhance sleep.
- D. Teach the client to develop a plan for daily structured activities.
Correct Answer: D
Rationale: The most effective intervention for a middle-aged adult with major depressive disorder experiencing psychomotor retardation, hypersomnia, and amotivation is to teach the client to develop a plan for daily structured activities. This intervention helps combat the symptoms by providing a routine and purpose to the client's day, addressing the issues of psychomotor retardation and amotivation. Structured activities can help establish a sense of normalcy, improve motivation, and regulate sleep patterns. Encouraging exercise (Choice A) can be beneficial but may be challenging for a client experiencing psychomotor retardation. Developing a list of pleasurable activities (Choice B) may not address the need for structure and routine in the client's daily life. Providing education on sleep enhancement methods (Choice C) is important but may not be sufficient to address the overall functional impairment in this case.
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The RN is teaching a client about the initiation of the prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding?
- A. Completely abstain from heroin or cocaine use.
- B. Remain alcohol-free for 12 hours prior to the first dose.
- C. Attend monthly meetings of Alcoholics Anonymous.
- D. Admit to others that he is a substance user.
Correct Answer: B
Rationale: The correct answer is B: "Remain alcohol-free for 12 hours prior to the first dose." It is essential for the client to understand the importance of abstaining from alcohol for at least 12 hours before starting disulfiram to prevent potential adverse reactions. Choice A is incorrect because disulfiram is specifically used to deter alcohol consumption, not heroin or cocaine use. Choice C is not directly related to the initiation of disulfiram therapy and attending AA meetings is not a requirement for taking disulfiram. Choice D is irrelevant and unnecessary for the initiation of disulfiram therapy.
An adolescent with anorexia nervosa is participating in a cognitive-behavioral therapy (CBT) program. Which behavior indicates that the therapy is effective?
- A. Client adheres to a meal plan and gains weight.
- B. Client discusses the impact of the disorder on family.
- C. Client expresses a desire to change behavior.
- D. Client reduces the frequency of binge eating.
Correct Answer: A
Rationale: In treating anorexia nervosa with cognitive-behavioral therapy (CBT), the primary goals are to normalize eating behaviors and achieve weight restoration. Therefore, adherence to a meal plan and weight gain are crucial indicators of treatment effectiveness. While discussing the impact of the disorder on the family (Choice B) can be beneficial for therapy, it may not directly indicate the effectiveness of CBT in treating anorexia nervosa. Expressing a desire to change behavior (Choice C) is a positive step, but actual behavioral changes such as adhering to a meal plan are more indicative of progress. Reducing the frequency of binge eating (Choice D) is more relevant for other eating disorders like bulimia nervosa, not anorexia nervosa.
A client with postpartum depression receives a prescription for sertraline (Zoloft). What information is most important to include in client teaching?
- A. Avoid foods high in tyramine, such as processed meats, red wine, and Swiss cheese.
- B. Contact the healthcare provider immediately if suicidal thoughts occur.
- C. Increase activity level to include regular exercise.
- D. Contact the healthcare provider immediately if muscle stiffness occurs.
Correct Answer: B
Rationale: The most critical information to include in client teaching for a client with postpartum depression starting sertraline (Zoloft) is to contact the healthcare provider immediately if suicidal thoughts occur. This is vital for the client's safety as antidepressants, including sertraline, can sometimes increase the risk of suicidal thoughts, especially at the start of treatment. Choices A, C, and D are not the most crucial information in this scenario. Choice A about avoiding foods high in tyramine is not directly related to sertraline use. Choice C about increasing activity level is important but not as critical as addressing suicidal ideation. Choice D about muscle stiffness is a potential side effect of sertraline but is not as urgent as monitoring for suicidal thoughts.
A teenager who has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the nurse to include in the client's plan of care?
- A. Initiate caloric and nutritional therapy.
- B. Implement behavioral modification therapy.
- C. Evaluate the client for low self-esteem.
- D. Record daily weights and graph trends.
Correct Answer: A
Rationale: The client presents with evidence of anorexia nervosa resulting from self-starvation, which is a life-threatening condition. Providing nutrition and calories is the priority intervention so that the risk of electrolyte imbalance and severe dehydration can be reduced. Behavioral modification therapy (Choice B) may be beneficial in the long term but is not the priority in this acute situation. Evaluating for low self-esteem (Choice C) may be part of the nursing assessment but does not address the immediate life-threatening issues. Recording daily weights and graphing trends (Choice D) is important for monitoring progress but does not address the critical need for nutritional therapy in this case.
What is the most appropriate intervention by the RN to address a client with obsessive-compulsive disorder (OCD) who repeatedly checks to see if the door is locked and asks for reassurance?
- 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: Setting a specific limit on the checking behavior is the most appropriate intervention for a client with OCD who repeatedly checks the door and seeks reassurance. This approach helps the client gradually reduce the compulsive behavior, promotes independence, and supports progress in treatment. Choice B is not the most suitable intervention as it does not directly address the compulsive checking behavior. Choice C, providing consistent reassurance, may reinforce the compulsive behavior and hinder treatment progress. Choice D of ignoring the behavior does not actively assist the client in managing their symptoms and addressing the underlying disorder.