Nokea
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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A client in the emergency department presents with confusion, disorientation, and agitation after drinking alcohol. Which diagnostic test should the nurse anticipate to assess for potential complications?
- A. Complete blood count (CBC)
- B. Electrolyte panel
- C. Liver function tests
- D. Urinalysis
Correct Answer: B
Rationale: The correct answer is an electrolyte panel. When a client presents with confusion, disorientation, and agitation after drinking alcohol, it indicates potential complications such as electrolyte imbalances. Monitoring electrolyte levels is crucial in these cases to detect and address abnormalities that may result from alcohol intake. While a complete blood count (choice A) may provide some valuable information, it is not the primary test to assess for alcohol-related complications presenting with these symptoms. Liver function tests (choice C) are more specific for assessing liver damage due to chronic alcohol use rather than immediate complications. Urinalysis (choice D) may help detect some issues but is not the most appropriate initial test to assess for potential complications in this scenario.
A male client approaches the RN with an angry expression on his face and raises his voice, saying, "My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!" The RN recognizes that the client is using which defense mechanism?
- A. Denial.
- B. Projection.
- C. Rationalization.
- D. Splitting.
Correct Answer: B
Rationale: The correct answer is B: Projection. Projection involves attributing one's own unacceptable feelings or thoughts to others, as seen in the client's accusations of his roommate's behavior. In this scenario, the client is projecting his own anger and potential for violence onto his roommate. Choice A, Denial, involves refusing to acknowledge some aspect of reality. Choice C, Rationalization, is a defense mechanism where logical reasons are given to justify behaviors that are actually based on unacceptable motives. Choice D, Splitting, is a defense mechanism where a person sees others as all good or all bad, not applicable in this case.
The nurse on the day shift receives report about a client with depression who was found on the floor in the morning. What intervention is best for the nurse to implement?
- A. Assist the client to get out of bed and involved in an activity.
- B. Monitor the client's appetite and sleep patterns.
- C. Assess the client's feelings regarding the hospital stay.
- D. Explain that staff will check on the client every 30 minutes.
Correct Answer: A
Rationale: Assisting the client to engage in activities is the best intervention as it can help improve mood and prevent further decline in function. Option B, monitoring appetite and sleep patterns, is important but not the most immediate intervention needed in this situation. Option C, assessing feelings about the hospital stay, is also important but addressing the client's physical safety and well-being should take precedence. Option D, explaining the frequency of staff checks, is not as effective in addressing the client's immediate needs for engagement and support.
A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN?
- A. Is attempting the physically restrain the patient.
- B. Remains at a distance of 4 feet from the client.
- C. Tells the client to go to the quiet area of the unit.
- D. Is using a loud voice to talk to the client.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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.