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Which client outcome indicates improvement for a client who is admitted with auditory hallucinations?
- A. Argues with the voices.
- B. Tells when voices decrease.
- C. Follows what the voices say.
- D. Tells the nurse what the voices say.
Correct Answer: B
Rationale: The correct answer is B: 'Tells when voices decrease.' This outcome indicates improvement because it shows that the client is experiencing a reduction in auditory hallucinations. By communicating that the voices are decreasing, it suggests that the client's symptoms are improving and the treatment is effective. Choices A, C, and D are incorrect. Arguing with the voices (A) indicates ongoing engagement with the hallucinations, which is not a positive outcome. Following what the voices say (C) suggests compliance with the hallucinations, which is not indicative of improvement. Lastly, telling the nurse what the voices say (D) does not necessarily demonstrate a reduction in hallucinations or improvement in the client's condition.
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A female client with post-traumatic stress disorder (PTSD) has been experiencing flashbacks. Which intervention should the nurse implement to help the client?
- A. Encourage the client to talk about the trauma.
- B. Advise the client to avoid triggers that cause flashbacks.
- C. Help the client stay grounded in the present moment.
- D. Refer the client to group therapy for PTSD.
Correct Answer: C
Rationale: The correct intervention for a client with PTSD experiencing flashbacks is to help them stay grounded in the present moment. This technique can reduce the intensity of flashbacks and provide a sense of safety. Encouraging the client to talk about the trauma (Choice A) may exacerbate the symptoms and should be done cautiously under professional guidance. Advising the client to avoid triggers (Choice B) is important, but solely relying on avoidance may not address the underlying issues. Referring the client to group therapy (Choice D) can be beneficial, but in the immediate context of managing flashbacks, grounding techniques are more appropriate.
A client with anorexia nervosa is being treated in an inpatient unit. Which intervention is a priority for the nurse?
- A. Encourage the client to exercise to build muscle mass.
- B. Provide liquid supplements between meals.
- C. Allow the client to choose their own meals.
- D. Monitor the client's weight daily.
Correct Answer: D
Rationale: Monitoring the client's weight daily is a priority intervention for a nurse caring for a client with anorexia nervosa. Weight monitoring is crucial in assessing the client's progress and adjusting treatment as necessary to prevent complications such as refeeding syndrome, electrolyte imbalances, and cardiac issues. Encouraging exercise (Choice A) can exacerbate the client's unhealthy relationship with food and body image. Providing liquid supplements (Choice B) is important but may not be the priority over monitoring weight. Allowing the client to choose their own meals (Choice C) may not be suitable initially as they may make unhealthy choices or avoid meals altogether.
A LVN/LPN is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that a client with anorexia nervosa manages anxiety by:
- A. Engaging in immoral acts
- B. Always reinforcing self-approval
- C. Observing rigid rules and regulations
- D. Having the need always to make the right decision
Correct Answer: C
Rationale: Clients with anorexia nervosa often manage anxiety by adhering strictly to rules and regulations as a way to maintain control. Choice A is incorrect because engaging in immoral acts is not a common coping mechanism for clients with anorexia nervosa. Choice B is incorrect as self-approval is not typically the primary way clients with anorexia nervosa manage anxiety. Choice D is incorrect because while clients with anorexia nervosa may have a need to make the right decision, it is not the primary way they manage their anxiety.
A client with depression is started on a selective serotonin reuptake inhibitor (SSRI). The client asks, 'How long will it take for this medication to work?' What is the best response by the nurse?
- A. It may take 2 to 4 weeks before you start feeling better.
- B. You should start feeling better within a few days.
- C. The medication works immediately to improve your mood.
- D. It may take up to 8 weeks for the medication to take full effect.
Correct Answer: D
Rationale: Explaining that it may take up to 8 weeks for the medication to take full effect provides the client with a realistic expectation. SSRI medications typically require time to build up in the body and exert their therapeutic effects. Choice A is incorrect as it underestimates the time frame required for the medication to work. Choice B is incorrect as SSRIs do not produce immediate effects. Choice C is incorrect as it falsely states that the medication works immediately, which is not true for SSRIs.
The LPN/LVN is caring for a client with depression who has been prescribed an SSRI. The client reports feeling more energy but is still feeling hopeless. What should the nurse be most concerned about?
- A. That the client may act on suicidal thoughts.
- B. That the client may engage in impulsive behavior.
- C. That the client may be experiencing the side effects of the medication.
- D. That the client may be at risk for developing serotonin syndrome.
Correct Answer: A
Rationale: The nurse should be most concerned that the client may act on suicidal thoughts. An increase in energy combined with persistent feelings of hopelessness can indicate a higher risk of suicide. While impulsive behavior can be a concern, the primary worry should be the client's safety regarding suicidal ideation. Side effects of the medication are important to monitor but do not take precedence over the risk of self-harm. Serotonin syndrome is a potential concern with SSRIs, but in this scenario, the client's mental health and safety are the immediate priority.