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What is the most therapeutic nursing response for a client with borderline personality disorder who engages in self-mutilating behavior?
- A. Encourage the client to stop hurting themselves.
- B. Discuss what the client was feeling before self-harming.
- C. Inform the client that the behavior will be reported to their doctor.
- D. Ask the client why they hurt themselves.
Correct Answer: B
Rationale: The most therapeutic nursing response for a client with borderline personality disorder engaging in self-mutilating behavior is to discuss what the client was feeling before self-harming. This approach helps in exploring the underlying triggers and emotions that lead to self-harm. Option A is directive and may come across as judgmental rather than empathetic. Option C can lead to feelings of betrayal and breach of trust. Option D is a closed-ended question that may not facilitate open communication or exploration of emotions.
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When a client with major depressive disorder expresses feelings of worthlessness and hopelessness, what is the nurse's priority intervention?
- A. Encourage the client to engage in recreational activities.
- B. Suggest the client keep a journal of their thoughts and feelings.
- C. Assess the client for suicidal ideation.
- D. Provide the client with positive affirmations.
Correct Answer: C
Rationale: The correct answer is to assess the client for suicidal ideation. When a client expresses feelings of worthlessness and hopelessness, it is crucial to evaluate the risk of self-harm. Encouraging recreational activities (choice A) or suggesting journaling (choice B) may be helpful interventions but assessing for suicidal ideation takes precedence due to the immediate risk of harm. Providing positive affirmations (choice D) is not the priority when safety is a concern.
Which statement best demonstrates the nurse's role in ensuring that each client's rights are respected?
- A. Autonomy is a fundamental right for each client.
- B. Client rights are guaranteed by both state and federal laws.
- C. Being respectful and concerned will ensure attentiveness to clients' rights.
- D. Regardless of the client's condition, nurses must respect client rights.
Correct Answer: C
Rationale: The statement 'Being respectful and concerned will ensure attentiveness to clients' rights' best demonstrates the nurse's role in ensuring that each client's rights are respected. This choice emphasizes the importance of being attentive and considerate towards clients to uphold their rights. Choice A is too general and lacks the direct connection to the nurse's role. Choice B highlights the legal aspect but does not specifically address the nurse's role. Choice D, although true, is not as comprehensive as choice C in describing the nurse's active role in respecting client rights.
The wife of a client diagnosed with paranoid schizophrenia visits 2 days after her husband's admission and states to the nurse, 'Why isn't he eating? He's still talking about his food being poisoned.' Which of the following appraisals by the LPN/LVN is most accurate?
- A. The wife's inquiry is reasonable.
- B. Education about her husband's medication is needed.
- C. Her expectations of her husband are realistic.
- D. An increase in the client's medication is needed.
Correct Answer: B
Rationale: The correct answer is B. The wife needs education about her husband's medication to understand how it affects his perceptions, including paranoid thoughts about food. Choice A is incorrect because the wife's inquiry reflects her lack of understanding of the situation rather than being reasonable. Choice C is incorrect as the husband's condition requires specialized care beyond what the wife might consider realistic. Choice D is incorrect as increasing medication should not be the immediate response; education and reassurance are key in this situation.
A client with schizophrenia is experiencing distressful thoughts secondary to paranoia. Which intervention(s) should the LPN/LVN include in the plan of care? Select one intervention that does not apply.
- A. Avoid laughing when near the client
- B. Whisper when communicating near the client
- C. Increase socialization of the client among peers
- D. Have the client sign a written release of information form
Correct Answer: B
Rationale: The correct intervention for a client with schizophrenia experiencing distressful thoughts secondary to paranoia is to avoid laughing when near the client. This is important as laughter can be misinterpreted and exacerbate the client's paranoia. Whispering when communicating near the client is not an appropriate intervention as it may lead the client to think secretive or negative information is being shared about them, further fueling their paranoia. Increasing socialization among peers can help provide support and reduce feelings of isolation, while having the client sign a written release of information form is not directly related to managing paranoia and distressful thoughts.
An elderly client was prescribed Ativan 1 mg three times a day to help calm her anxiety after her husband's death. The next day the client calls her daughter asking when she is picking her up to go to the graveside. The client says she has been walking up and down the driveway for the past hour waiting for her daughter. Noting the client's agitation, hyperactivity, and insistence, the daughter calls the nurse to report her mother's behavior. What should the nurse suspect?
- A. The client is manic and may need a sleeping pill
- B. The client is experiencing a medication interaction and should go to the ED
- C. The client is experiencing a paradoxical reaction to the Ativan and should stop the new medication immediately
- D. The client is overcome by grief and probably needs an antidepressant
Correct Answer: C
Rationale: A paradoxical reaction to Ativan, where the drug causes opposite effects such as increased agitation and hyperactivity, should prompt immediate cessation of the medication. In this scenario, the client was prescribed Ativan to help calm her anxiety, but instead, she is displaying symptoms of increased agitation and hyperactivity, indicating a paradoxical reaction. Choice A is incorrect because the symptoms described do not align with mania. Choice B is incorrect as there is no mention of a medication interaction. Choice D is incorrect as the symptoms are more indicative of a paradoxical reaction rather than overwhelming grief.