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Which of the following interventions is most appropriate for a client experiencing severe anxiety?
- A. Encourage the client to talk about their feelings.
- B. Provide a quiet and calm environment.
- C. Encourage the client to exercise vigorously.
- D. Encourage the client to participate in group activities.
Correct Answer: B
Rationale: In cases of severe anxiety, creating a quiet and calm environment is crucial as it can help reduce stimulation and promote relaxation. This environment can provide a sense of safety and security, which are essential for individuals experiencing heightened anxiety levels. Encouraging the client to talk about their feelings may not be suitable during severe anxiety as it can further escalate distress by focusing on the source of anxiety. Vigorous exercise and group activities may not be appropriate initially, as they can increase arousal levels rather than promoting a sense of calm needed to manage severe anxiety.
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A client with bipolar disorder is in the manic phase. Which nursing intervention should the nurse implement to ensure the client's safety?
- A. Provide a structured environment with minimal stimuli.
- B. Encourage the client to participate in group activities.
- C. Monitor the client closely for signs of exhaustion.
- D. Encourage the client to rest and sleep as needed.
Correct Answer: A
Rationale: During the manic phase of bipolar disorder, individuals may engage in impulsive behaviors that can put them at risk of harm. Providing a structured environment with minimal stimuli can help reduce the risk of injury by minimizing triggers for impulsive actions. This intervention promotes a safe and controlled setting for the client, which is crucial in managing the symptoms of mania. Encouraging the client to participate in group activities (Choice B) may increase stimuli and potentially exacerbate manic symptoms. Monitoring for signs of exhaustion (Choice C) is important but does not directly address the safety concerns related to impulsive behaviors during mania. Encouraging the client to rest and sleep as needed (Choice D) may be challenging during the manic phase when individuals typically experience decreased need for sleep.
A client with generalized anxiety disorder is prescribed buspirone. Which statement by the client indicates a need for further teaching?
- A. I can stop taking this medication once I feel less anxious.
- B. I should avoid drinking alcohol while taking this medication.
- C. It may take several weeks for this medication to take full effect.
- D. This medication can cause dependency.
Correct Answer: A
Rationale: The correct answer is A because it indicates a misunderstanding about buspirone. Buspirone should not be abruptly stopped, and patients should follow the prescribed regimen consistently. Stopping the medication without proper guidance can lead to adverse effects or a return of anxiety symptoms. Choices B, C, and D demonstrate an understanding of important aspects of buspirone therapy: avoiding alcohol due to interactions, being patient for the medication to reach full effectiveness, and being aware of the potential for dependency with this medication.
A client has been prescribed a monoamine oxidase inhibitor (MAOI). Which dietary restriction should the nurse emphasize during discharge instructions?
- A. Avoid foods high in potassium.
- B. Avoid foods high in calcium.
- C. Avoid foods high in tyramine.
- D. Avoid foods high in sodium.
Correct Answer: C
Rationale: The correct answer is C: Avoid foods high in tyramine. Clients taking MAOIs should avoid foods high in tyramine to prevent hypertensive crisis. Tyramine is found in aged, fermented, or spoiled foods. Choices A, B, and D are incorrect because potassium, calcium, and sodium restrictions are not specifically required for clients taking MAOIs.
A client diagnosed with major depressive disorder is receiving cognitive-behavioral therapy (CBT). Which outcome indicates that the therapy is effective?
- A. The client identifies and challenges negative thoughts.
- B. The client reports an increase in suicidal thoughts.
- C. The client experiences an increase in anxiety.
- D. The client shows no change in behavior.
Correct Answer: A
Rationale: In cognitive-behavioral therapy (CBT), one of the primary objectives is to help clients identify and challenge their negative thoughts. This process allows the individual to reframe their thinking patterns and develop more adaptive coping strategies. Reporting an increase in suicidal thoughts (Choice B) or experiencing an increase in anxiety (Choice C) are not desired outcomes and may indicate a need for further intervention. Showing no change in behavior (Choice D) suggests that the therapy has not been effective. Therefore, the correct indicator of effective therapy in this context is the client's ability to identify and challenge negative thoughts (Choice A).
After fasting from 10 p.m. the previous evening, a client finds out that the blood test has been canceled. The client swears at the nurse and states, 'You are incompetent!' Which is the nurse's best response?
- A. Do you believe that I was the cause of your blood test being canceled?
- B. I see that you are upset, but I feel uncomfortable when you swear at me.
- C. Have you ever thought about ways to express anger appropriately?
- D. I'll give you some space. Let me know if you need anything.
Correct Answer: B
Rationale: In this scenario, the most appropriate response for the nurse is option B. By acknowledging the client's feelings and setting a boundary regarding inappropriate behavior, the nurse addresses the situation with empathy. This response demonstrates understanding of the client's emotions while also maintaining a professional standard by expressing discomfort with swearing. Option A could come off as defensive and may escalate the situation. Option C may be perceived as condescending and not immediately address the client's behavior. Option D, although offering space, does not directly address the inappropriate behavior and misses an opportunity to set a professional boundary.