Nokea
Which of the following interventions should be implemented for a client with anorexia nervosa? Select one that does not apply.
- A. Monitor daily caloric intake and weight
- B. Establish a structured eating plan
- C. Encourage the client to exercise
- D. Provide liquid supplements as prescribed
Correct Answer: C
Rationale: Interventions for a client with anorexia nervosa include monitoring daily caloric intake and weight, establishing a structured eating plan, providing liquid supplements as prescribed, and offering rewards for weight gain. However, encouraging the client to exercise is not appropriate as it may exacerbate the condition by increasing caloric expenditure and reinforcing unhealthy behaviors associated with the disorder. Exercise may further contribute to excessive weight loss and worsen the client's physical health in the context of anorexia nervosa.
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Which is a correct evaluation of the new psychiatric nurse's statement regarding a client's use of defense mechanisms?
- A. Defense mechanisms can be self-protective responses to stress and need not be eliminated.
- B. Defense mechanisms are a maladaptive attempt by the ego to manage anxiety and should always be eliminated.
- C. Defense mechanisms, used by individuals with weak ego integrity, should be discouraged but not eliminated.
- D. Defense mechanisms cause disintegration of the ego and should be fostered and encouraged.
Correct Answer: A
Rationale: The correct evaluation is that defense mechanisms can be self-protective responses to stress and do not necessarily need to be eliminated. These mechanisms serve the purpose of reducing anxiety during times of stress. While some defense mechanisms may be maladaptive, they can also help individuals cope with challenging situations. It is essential for the nurse to recognize that addressing defense mechanisms should be done sensitively, as they may be crucial for the client's emotional regulation. Encouraging the development of healthy coping skills while acknowledging the role of defense mechanisms in managing stress is a balanced approach in psychiatric care. Choice B is incorrect because completely eliminating defense mechanisms is not always feasible or beneficial. Choice C is incorrect as it oversimplifies the relationship between defense mechanisms and ego integrity. Choice D is incorrect as it misrepresents the role of defense mechanisms in ego functions.
When assessing a client diagnosed with post-traumatic stress disorder (PTSD), which finding should the nurse expect?
- A. Hypervigilance
- B. Insomnia
- C. Flashbacks
- D. Suicidal ideation
Correct Answer: A
Rationale: Clients with PTSD commonly exhibit symptoms such as hypervigilance, insomnia, flashbacks, difficulty concentrating, and increased irritability. Hypervigilance refers to an enhanced state of awareness and alertness, often seen in individuals with PTSD as they are constantly on guard for potential threats. Insomnia is a common sleep disturbance associated with PTSD, where individuals may have trouble falling or staying asleep. Flashbacks involve re-experiencing the traumatic event as if it is occurring in the present moment. Suicidal ideation, while a serious concern in mental health, is not a hallmark symptom specifically associated with PTSD. Therefore, the correct finding that the nurse should expect when assessing a client diagnosed with PTSD is hypervigilance.
Upon admission, a client diagnosed with major depressive disorder needs the nurse to implement which of the following interventions first?
- A. Administer an antidepressant medication.
- B. Establish a trusting relationship with the client.
- C. Develop a plan of care with the client.
- D. Teach the client about the importance of medication compliance.
Correct Answer: B
Rationale: The initial intervention the nurse should prioritize is to establish a trusting relationship with the client. Building trust is fundamental in fostering effective therapeutic communication and providing quality care. This foundational step lays the groundwork for further assessment, collaboration on care plans, and promoting treatment adherence. Administering medication or discussing compliance should come after the establishment of trust to ensure the client feels supported and understood.
A client has been prescribed escitalopram (Lexapro) for depression. Which instruction should the nurse include in the discharge teaching?
- A. Take the medication at bedtime to prevent daytime drowsiness.
- B. Avoid consuming alcohol while taking this medication.
- C. Take the medication with food to prevent stomach upset.
- D. Discontinue the medication if you start feeling better.
Correct Answer: B
Rationale: The correct instruction for the nurse to include in the discharge teaching is to advise the client to avoid consuming alcohol while taking escitalopram (Lexapro). Alcohol can potentiate side effects such as drowsiness and dizziness when combined with this medication. Choice A is incorrect because escitalopram is usually taken in the morning due to its potential to cause insomnia if taken at bedtime. Choice C is incorrect because taking the medication with or without food does not significantly affect its absorption or side effects. Choice D is incorrect because it is essential for the client to continue taking the medication even if they start feeling better, as abruptly stopping an antidepressant can lead to withdrawal symptoms and a relapse of depression.
A healthcare provider is assessing a client diagnosed with avoidant personality disorder. Which of the following behaviors should the healthcare provider expect?
- A. Social inhibition
- B. Fear of criticism
- C. Desire for close relationships
- D. Fear of abandonment
Correct Answer: A
Rationale: Individuals with avoidant personality disorder commonly display social inhibition and a fear of criticism or rejection. While they may have a desire for close relationships, they tend to avoid them due to their fear of disapproval and negative evaluation by others. Fear of criticism (Choice B) is also a characteristic behavior seen in individuals with avoidant personality disorder. However, the primary behavior associated with this disorder is social inhibition (Choice A), where individuals tend to be reserved and avoid social interactions. Desiring close relationships (Choice C) may be present, but the fear of rejection typically prevents individuals from pursuing these relationships. Fear of abandonment (Choice D) is more commonly associated with borderline personality disorder rather than avoidant personality disorder.