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Which of the following questions is best to ask when assessing the client's judgment?
- A. Can you describe your usual daily activities for me?'
- B. If you found yourself downtown without money or a car, how would you get home?'
- C. On a scale of 1 to 10, how stressed would you rate yourself?'
- D. What problem would you like to work on while you're hospitalized?'
Correct Answer: B
Rationale: Judgment refers to the ability to interpret one's environment and situation correctly and to adapt one's own behavior and decisions accordingly. This question will elicit information about the client's problem-solving and decision-making abilities. The other choices do not assess the concept of judgment.
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A nurse is working with a patient diagnosed with post-traumatic stress disorder (PTSD). Which of the following interventions would be most appropriate for this patient?
- A. Provide exposure therapy to confront trauma-related memories.
- B. Encourage the patient to avoid any discussions about the traumatic event.
- C. Administer sedative medications to manage anxiety during flashbacks.
- D. Help the patient identify coping mechanisms and support systems.
Correct Answer: D
Rationale: Helping the patient identify effective coping mechanisms and support systems is an essential part of treating PTSD and improving the patient's ability to manage stress.
A nurse is caring for a patient diagnosed with a mood disorder who is taking lithium. Which side effect of lithium should the nurse closely monitor for?
- A. Tremors, nausea, and weight gain.
- B. Blurred vision, dizziness, and hyperactivity.
- C. Polyuria, polydipsia, and fine hand tremors.
- D. Fatigue, drowsiness, and headache.
Correct Answer: C
Rationale: Polyuria, polydipsia, and fine hand tremors are common side effects of lithium, and the nurse should monitor for these signs to prevent toxicity and ensure proper medication management.
A patient diagnosed with major depressive disorder has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken antidepressant medication for 1 week. Which nursing intervention has the highest priority?
- A. Implement suicide precautions.
- B. Offer high-calorie snacks and fluids frequently.
- C. Assist the patient to identify three personal strengths.
- D. Observe patient for therapeutic effects of antidepressant medication.
Correct Answer: A
Rationale: Implementing suicide precautions is the only option related to patient safety. The other options, related to nutrition, self-esteem, and medication therapy, are important but are not priorities.
A nurse is developing a discharge plan for a client who is in a detoxification unit. The nurse should include which of the following in the client's relapse prevention plan?
- A. Limit partying with former friends to once weekly, lock up substances in the home, and turn over finances to another person.
- B. Find a support person or sponsor, identify triggers, and develop new coping skills.
- C. Isolate at home, take leave of absence from job, and limit social contacts.
- D. Solicit a support person to transport to meetings, live in the home with client, and prevent them from using the substance.
Correct Answer: B
Rationale: A relapse prevention plan should include finding a support person or sponsor, identifying triggers, and developing new coping skills. These strategies help the client maintain sobriety and manage potential triggers.
When providing care for a client who is terminally ill, how can the nurse assess and support the client’s spiritual distress? Select one that does not apply.
- A. Asking about the client’s spiritual practices and preferences
- B. Connecting the client to spiritual support persons in the hospital or community
- C. Incorporating prayer or other religious practices into the care of the client when able
- D. Avoiding discussing spirituality to avoid confusion and conflict
Correct Answer: D
Rationale: Addressing spiritual distress involves understanding the client’s preferences, connecting them with support, and incorporating their practices into care. Avoiding the topic can exacerbate distress.