Nokea
Which therapeutic nursing intervention is most beneficial for a client diagnosed with post-traumatic stress disorder (PTSD)?
- A. Administering antianxiety medications
- B. Monitoring the client's physical symptoms
- C. Encouraging the client to express feelings
- D. Investigating the client's current family interactions
Correct Answer: C
Rationale: Expressing feelings helps process trauma, reducing PTSD symptoms by fostering emotional regulation and insight.
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Staff are debriefing following the client’s violent episode. Which information should be included in the debriefing session? Select all that apply.
- A. Client’s coping mechanisms post-event
- B. The client’s history of violent behavior
- C. Adherence to instructional policies and procedures
- D. Staff’s feelings regarding the effectiveness of the team
- E. Staff’s ability to respond to the client therapeutically post-event
Correct Answer: C ,D, E
Rationale: Debriefing includes policy adherence (C) team effectiveness (D) and therapeutic response (E) to identify training needs. Client coping (A) and history (B) are not debriefing focuses.
When the nurse reviews information about lithium carbonate (Lithane) with the client, which instructions are most important to stress? Select all that apply.
- A. Take a high-potency vitamin each morning.
- B. Refrain from sexual activity while taking this medication.
- C. Notify the physician if urine output increases.
- D. Maintain an adequate intake of sodium and fluids.
- E. Have periodic blood tests to monitor serum levels of the drug.
Correct Answer: C,D,E
Rationale: Monitoring urine output, maintaining sodium/fluid balance, and regular blood tests are critical to prevent lithium toxicity and ensure safe therapy.
When resuscitation efforts are unsuccessful, which nursing action is most appropriate?
- A. Ask the parents for permission to perform an autopsy.
- B. Ask about the possibility of harvesting the infant's organs for transplantation.
- C. Check on the parents' choice for the funeral arrangements.
- D. Take the parents to a room where they can be with the baby.
Correct Answer: D
Rationale: Allowing parents to spend time with their deceased infant supports grieving and closure, prioritizing their emotional needs immediately after the loss.
Which of the following nursing assessment data places the client at highest risk for suicide?
- A. The client feels hopeless about the future.
- B. The client has a plan in mind for suicide.
- C. The client states that death would end the misery.
- D. The client says the distress is intolerable.
Correct Answer: B
Rationale: A specific suicide plan indicates high risk, as it shows intent and means, requiring immediate intervention.
Which action is most appropriate for the nurse to take first?
- A. Remind the client that clothes are required in public.
- B. Instruct the client to put clothes on again.
- C. Explain to the residents that the client is not of sound mind.
- D. Take the client to a vacant room nearby.
Correct Answer: D
Rationale: Taking the client to a private room ensures dignity and safety, addressing the immediate need without public confrontation.