Nokea
Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior?
- A. Administer a prescribed PRN antianxiety medication.
- B. Assist the client in identifying stimuli that precipitate the ritualistic activity.
- C. Allow time for the ritualistic behavior, then redirect the client to other activities.
- D. Teach the client relaxation and thought-stopping techniques.
Correct Answer: C
Rationale: Initially, the nurse should allow time for the ritualistic behavior (C) to prevent anxiety. Administering an antianxiety medication (A) may help reduce the client's anxiety temporarily but will not address the underlying issue of ineffective coping mechanisms leading to the behavior. While assisting the client in identifying triggers (B) is important for long-term therapy, the immediate focus should be on managing the behavior. Teaching relaxation and thought-stopping techniques (D) is beneficial but might be more effective once the client is more stable and receptive to learning new coping strategies.
You may also like to solve these questions
The LPN/LVN is caring for a client who has recently been diagnosed with bipolar disorder. The client asks, 'Why do I have to take medication every day?' What is the best response by the nurse?
- A. The medication will help stabilize your mood and prevent mood swings.
- B. You will need to take this medication for the rest of your life.
- C. The medication will help you feel better and more in control of your emotions.
- D. The medication is needed to control your symptoms and help you function better.
Correct Answer: A
Rationale: The best response by the nurse is to explain that the medication will help stabilize the client's mood and prevent mood swings. This response provides the client with a clear understanding of how the medication works in managing bipolar disorder. Choice B is not the best response as it may cause unnecessary worry about lifelong medication dependence. Choice C is not as specific in addressing the purpose of the medication for bipolar disorder. Choice D is not as focused on the effect of the medication on mood stabilization, which is crucial in managing bipolar disorder.
A client with schizophrenia is being discharged with a prescription for risperidone (Risperdal). What is the most important instruction for the nurse to provide?
- A. Stop taking the medication if you start feeling better.
- B. Be aware of the potential for weight gain with this medication.
- C. Report any unusual muscle movements immediately.
- D. You can drive as soon as you feel ready.
Correct Answer: C
Rationale: The correct answer is C: "Report any unusual muscle movements immediately." Unusual muscle movements may indicate extrapyramidal symptoms (EPS) or tardive dyskinesia, which are serious side effects of antipsychotic medications like risperidone. It is crucial to address these symptoms promptly to prevent long-term effects. Choice A is incorrect because stopping the medication suddenly can be dangerous and should only be done under medical supervision. Choice B, while important, is not the most critical instruction in this scenario. Choice D is also incorrect as the ability to drive may be affected by the medication and should be discussed with a healthcare provider.
Which diet selection by a client who is depressed and taking the MAO inhibitor tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen?
- A. Hamburger, French fries, and chocolate milkshake.
- B. Liver and onions, broccoli, and decaffeinated coffee.
- C. Pepperoni and cheese pizza, tossed salad, and a soft drink.
- D. Roast beef, baked potato with butter, and iced tea.
Correct Answer: D
Rationale: Roast beef, baked potato with butter, and iced tea are safe choices as they do not contain tyramine, which must be avoided with MAO inhibitors like Parnate. Tyramine-rich foods like aged cheeses, certain meats, and fermented products can cause a hypertensive crisis when combined with MAO inhibitors. Choices A, B, and C contain foods high in tyramine and are not recommended for individuals taking MAO inhibitors.
A client is responding to auditory hallucinations and shakes a fist at a nurse and says, 'Back off, witch!' The nurse follows the client into the day room. What action should the nurse implement?
- A. Sit down in a chair near the client.
- B. Position self within an arm's length of the client.
- C. Ensure that there is physical space between the nurse and client.
- D. Move to a position that allows the client to be closest to the room's door.
Correct Answer: C
Rationale: In situations where a client is responding to auditory hallucinations and displaying aggressive behavior, it is crucial for the nurse to ensure physical space between themselves and the client. This action can help de-escalate the situation and prevent any potential harm to both the nurse and the client. Sitting down near the client (Choice A) may escalate the situation by invading the client's personal space. Positioning oneself within an arm's length of the client (Choice B) may increase the risk of physical confrontation. Moving closer to the room's door (Choice D) may not be appropriate as it can block the client's exit route and escalate the situation further. Therefore, ensuring physical space between the nurse and the client (Choice C) is the most appropriate action to promote safety and prevent escalation.
A client with generalized anxiety disorder is being treated with lorazepam (Ativan). What is the most important teaching point for the LPN/LVN to reinforce?
- A. Take the medication on an empty stomach.
- B. Avoid drinking alcohol while taking this medication.
- C. This medication may cause drowsiness, so avoid driving.
- D. You can stop taking the medication once you feel better.
Correct Answer: B
Rationale: The most important teaching point for the LPN/LVN to reinforce is to avoid drinking alcohol while taking lorazepam (Ativan). Alcohol can enhance the sedative effects of lorazepam, increasing the risk of severe side effects and complications. Choice A is incorrect because lorazepam can be taken with or without food. Choice C is not the most critical teaching point, although it is essential to avoid activities that require mental alertness until the effects of the medication are known. Choice D is incorrect because abruptly stopping lorazepam can lead to withdrawal symptoms and should only be done under medical supervision.