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When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?
- A. Involve client in daily exercise program
- B. Ask the client to describe her depression
- C. Spend time sitting in silence with client
- D. Observe for signs of possible psychosis
Correct Answer: C
Rationale: Spending time sitting in silence with the client provides a supportive presence without pressure for immediate responses, which is helpful for depression-related delays in communication. Exercise may be beneficial but does not address delayed responses directly. Asking about depression is useful for assessment but not immediate needs. Observing for psychosis is not indicated unless other symptoms are present.
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The nurse continues caring for the client:
The client is a 26-year-old female who was in a car accident 6 months s ago that killed her mother, husband, and 2-year-old son. She and her father were the only survivors of the crash. She is seeking care for depression.
Click to indicate whether findings at the next follow-up appointment indicate that the treatment was effective or ineffective. Each row must have one response selected.
- A. The client talks to her father and her best friend when she starts to feel sad: Effective
- B. The client states she feels numb when thinking about the crash: Ineffective
- C. The client states that she avoids driving altogether and takes the bus: Effective
- D. The client reports sleeping 6 to 7 hours per night: Effective
- E. The client states she feels less jumpy and more relaxed: Effective
Correct Answer: A,B,C,D,E
Rationale: A: Seeking support is a positive coping mechanism (Effective). B: Numbness suggests unresolved trauma (Ineffective). C: Avoiding driving reduces distress (Effective). D: Adequate sleep indicates improvement (Effective). E: Reduced anxiety shows treatment efficacy (Effective).
A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determine the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?
- A. Ineffective community coping
- B. Disturbed sensory perception
- C. Self-care deficit
- D. Acute confusion
Correct Answer: D
Rationale: Acute confusion is the priority problem because the client is disoriented, disorganized, and confused, indicating a cognitive impairment that needs immediate attention. Ineffective community coping may be a concern for a homeless individual but is not the priority in this scenario. Disturbed sensory perception typically involves alterations in visual, auditory, tactile, or olfactory senses, which may not be the primary issue. While self-care deficit could be a concern, it is not the priority when the client is disoriented.
A client who has agoraphobia is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?
- A. Establish trust by providing a calm, safe environment
- B. Encourage deep breathing when anxiety escalates in a crowd
- C. Progressively expose the client to larger crowds
- D. Encourage substitution of positive thoughts for negative ones
Correct Answer: A
Rationale: Establishing trust through a calm, safe environment is foundational for effective desensitization in agoraphobia, supporting the client's sense of security. Deep breathing and positive thoughts are secondary. Progressive exposure comes after trust is established.
A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone. When the client walks to the nurse's station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?
- A. Administer the prescribed anticholinergic benztropine for dystonia
- B. Offer the client a prescribed physical therapy hot pack for muscle spasms
- C. Direct the client to occupational therapy to distract him from somatic complaints
- D. Medicate the client with the prescribed antipsychotic thioridazine
Correct Answer: A
Rationale: The client's laterally contracted position and perception of contortion suggest acute dystonia, a side effect of risperidone. Benztropine, an anticholinergic, alleviates dystonia. Hot packs, occupational therapy, or thioridazine do not address this acute reaction.
A client requests permission for the spouse to remain in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. Which action should the nurse take?
- A. Ignore the nonverbal behavior and focus on the client's verbal messages
- B. Integrate the verbal and nonverbal messages and interpret them as one
- C. Ask the client's spouse to interpret the discrepancy
- D. Pay close attention and document the nonverbal messages
Correct Answer: D
Rationale: Paying close attention and documenting nonverbal messages gathers comprehensive data for further exploration. Ignoring nonverbal cues misses important information. Integrating messages prematurely may misinterpret the discrepancy. Asking the spouse to interpret is inappropriate and may not be accurate.