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When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?
- A. Impaired comfort.
- B. Risk for injury.
- C. Ineffective breathing pattern.
- D. Ineffective coping.
Correct Answer: C
Rationale: The correct answer is C: Ineffective breathing pattern. This is the highest priority because aspiration of a caustic material can lead to respiratory distress or compromise. Ensuring the client has a patent airway and adequate breathing is crucial for immediate stabilization and preventing further complications. Impaired comfort (choice A) may be a concern but is secondary to ensuring the client can breathe. Risk for injury (choice B) is important but not as immediate as addressing breathing. Ineffective coping (choice D) is important for long-term recovery but addressing the client's breathing takes precedence in this acute situation.
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What assessment question will provide the nurse with information regarding the effects of a woman’s circadian rhythms on her quality of life?
- A. I notice that you frowned and avoided eye contact just now. Don’t you feel well?
- B. Does your heart ever seem to skip a beat?
- C. When was the last time you had a fever?
- D. Do you have problems urinating?
- E. How much sleep do you usually get each night?
Correct Answer: E
Rationale: The correct answer is E: How much sleep do you usually get each night? This question directly addresses the effects of circadian rhythms on the woman's quality of life as sleep patterns are regulated by these rhythms. By understanding her typical sleep duration, the nurse can assess if her circadian rhythms are impacting her quality of life. Choices A, B, C, and D do not specifically address circadian rhythms and their effects. A focuses on general well-being, B on cardiac issues, C on fever, and D on urinary problems. These options do not provide relevant information about circadian rhythms and their impact on quality of life, making them incorrect in this context.
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.
The RN is leading a group on the inpatient psychiatric unit. Which approach should the RN use during the working phase of group development?
- A. Establishing a rapport with group members.
- B. Clarifying the nurse’s role and clients’ responsibilities.
- C. Discussing ways to use new coping skills learned.
- D. Helping clients identify areas of problem in their lives.
Correct Answer: C
Rationale: The correct answer is C: Discussing ways to use new coping skills learned. During the working phase of group development, the focus is on implementing and practicing new skills and strategies. This helps group members apply what they have learned to their real-life situations. By discussing ways to use new coping skills, the RN is facilitating the group's progress towards achieving their therapeutic goals.
A: Establishing a rapport with group members is important in the initial phase of group development, not during the working phase.
B: Clarifying the nurse’s role and clients’ responsibilities is more relevant to the orientation phase, not the working phase.
D: Helping clients identify areas of problem in their lives is typically done in the initial assessment phase, not during the working phase.
Which statement demonstrates a well-structured attempt at limit setting?
- A. Hitting me when you are angry is unacceptable.
- B. I expect you to behave yourself during dinner.
- C. Come here, right now!
- D. Good boys don’t bite.
Correct Answer: A
Rationale: The correct answer is A because it clearly communicates the behavior that is unacceptable (hitting when angry) and sets a clear boundary. It addresses the specific behavior and its consequences without being vague or ambiguous. Choice B lacks specificity, choice C is a command without explaining the reason for the request, and choice D uses shaming language which is not effective in setting limits. Choices E, F, and G are irrelevant as they are not provided. Overall, choice A demonstrates a well-structured attempt at limit setting by being clear, specific, and focusing on the behavior that needs to change.
You have been working closely with a patient for the past month. Today he tells you he is looking forward to meeting with his new psychiatrist but frowns and avoids eye contact while reporting this to you. Which of the following responses would most likely be therapeutic?
- A. A new psychiatrist is a chance to start fresh; I’m sure it will go well for you.
- B. You say you look forward to the meeting, but you appear anxious or unhappy.
- C. I notice that you frowned and avoided eye contact just now. Don’t you feel well?
- D. I get the impression you don’t really want to see your psychiatrist—can you tell me why?
Correct Answer: B
Rationale: The correct answer is B. This response acknowledges the patient's non-verbal cues and reflects back to the patient what you observed, showing empathy and understanding. It validates the patient's emotions and opens up the opportunity for the patient to further elaborate on their feelings. Choice A minimizes the patient's feelings and may come off as dismissive. Choice C puts the patient on the spot and may make them defensive. Choice D makes an assumption about the patient's feelings without giving them a chance to express themselves.