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While working with a male client at a community mental health center, the client reports hearing voices that tell him to get a knife from the kitchen and hurt himself. What intervention is most important for the RN to implement?
- A. Prevent the client from going into the kitchen until the hallucination has subsided.
- B. Report the behavior to the client's case workers to notify the family.
- C. Assign a UAP to stay with the client continuously.
- D. Document the behavior in the client's record and inform the HCP.
Correct Answer: A
Rationale: Preventing the client's access to potential means of self-harm is the immediate priority to ensure his safety. While it is crucial to report concerning behaviors to the client's case workers for further support, addressing the immediate risk of harm takes precedence. Assigning a UAP to stay with the client is important for continuous monitoring but is secondary to ensuring immediate safety. Documenting the behavior in the client's record and notifying the healthcare provider are essential steps in the care process; however, they should follow actions taken to ensure the client's immediate safety.
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An adolescent with a history of bipolar disorder is hospitalized during a manic episode. Which intervention is most appropriate for the nurse to include in the care plan?
- A. Encourage high levels of physical activity.
- B. Provide a quiet and structured environment.
- C. Engage the client in creative arts activities.
- D. Allow the client to make decisions about their schedule.
Correct Answer: B
Rationale: During a manic episode, individuals with bipolar disorder may experience heightened energy levels, decreased need for sleep, and racing thoughts. Providing a quiet and structured environment is crucial in managing these symptoms as it helps reduce external stimuli, prevent overstimulation, and promote a sense of calmness. Encouraging high levels of physical activity may exacerbate the manic symptoms by further increasing stimulation and excitement. Engaging the client in creative arts activities might be beneficial during stable periods but may not be the most appropriate intervention during a manic episode. Allowing the client to make decisions about their schedule could potentially lead to impulsivity and poor judgment, which are common characteristics of mania.
A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement?
- A. Isolate the client from the other clients.
- B. Administer PRN sedative.
- C. Avoid recognizing the behavior.
- D. Escort the client to his room.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
An antidepressant medication is prescribed for a client who reports sleeping only 4 hours in the past 2 days and weight loss of 9 lbs within the last month. Which client goal is most important to achieve within the first three days of treatment?
- A. Meet scheduled appointment with a dietitian.
- B. Sleep at least 6 hours a night.
- C. Understand the purpose of the medication regimen.
- D. Describe the reasons for hospitalization.
Correct Answer: B
Rationale: The most important goal to achieve within the first three days of treatment is to ensure the client can sleep at least 6 hours a night. Adequate sleep is essential for stabilizing mood and improving overall functioning. Choice A is not as urgent as improving sleep patterns. Choice C is important but not as immediate as addressing the sleep deficit. Choice D is unrelated to the immediate treatment goal of improving sleep and managing symptoms of depression.
A male client comes to the emergency center with an erection that will not resolve. The client reports that he is taking trazodone (Desyrel) for insomnia. Which information is most important for the nurse to ask this client?
- A. Have you taken any medication for erectile dysfunction?
- B. Are you experiencing any other sexual dysfunctions or problems?
- C. When was the last time you consumed an alcoholic beverage?
- D. Do you have a history of angina or high blood pressure?
Correct Answer: B
Rationale: In this scenario, the most important question for the nurse to ask the client is whether he is experiencing any other sexual dysfunctions or problems. This inquiry is crucial as it can help in determining if the persistent erection is a side effect of trazodone. Asking about medication for erectile dysfunction (Choice A) may not provide relevant information in this case, as the focus is on the potential side effects of trazodone. Inquiring about the last time the client consumed alcohol (Choice C) is not directly related to the situation at hand. Questioning about a history of angina or high blood pressure (Choice D) is important for overall assessment but is not as directly relevant to the immediate concern of the persistent erection potentially caused by trazodone.
An elderly client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. Which assessment finding is most concerning for the nurse?
- A. Weight loss of 5 pounds in one week.
- B. Lack of interest in previously enjoyed activities.
- C. Disorganized speech and thought processes.
- D. Severe fatigue and low energy levels.
Correct Answer: C
Rationale: In an elderly client with major depressive disorder, disorganized speech and thought processes are the most concerning assessment finding for the nurse. These symptoms can suggest a more severe condition such as psychosis or cognitive impairment, which require immediate attention and intervention. Weight loss, lack of interest in activities, severe fatigue, and low energy levels are common symptoms of major depressive disorder but do not pose an immediate risk as disorganized speech and thought processes do.