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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.
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A RN is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview?
- A. Dim the lights in the room to help the patient feel calm.
- B. Sit within two feet of the client to enhance the level of safety and security.
- C. Reduce the noise level in the room by turning off the television and radio.
- D. Position a table between the client and the RN for extra personal space.
Correct Answer: C
Rationale: Reducing the noise level in the room by turning off the television and radio is the best choice among the options provided. This setting helps create a calm and focused environment, which facilitates better communication and assessment during the interview. Dimming the lights might not be suitable for all clients and could potentially hinder communication. Sitting too close or placing a table between the client and the RN may affect the client's comfort level and openness during the interview.
A male client with alcohol use disorder is admitted for detoxification. The nurse knows that which symptom is a sign of severe alcohol withdrawal?
- A. Bradycardia
- B. Seizures
- C. Hyperglycemia
- D. Constipation
Correct Answer: B
Rationale: Seizures are a sign of severe alcohol withdrawal and can be life-threatening, requiring immediate medical attention. Bradycardia, hyperglycemia, and constipation are not typically associated with severe alcohol withdrawal. Bradycardia is more commonly seen in opioid withdrawal, hyperglycemia could be due to other reasons like uncontrolled diabetes, and constipation is not a typical symptom of severe alcohol withdrawal.
A nurse is providing discharge teaching to a client with schizophrenia who is prescribed clozapine (Clozaril). Which information should the nurse include?
- A. You need to come in for regular blood tests.
- B. This medication can cause weight loss.
- C. You can stop taking this medication once you feel better.
- D. Avoid foods high in tyramine while on this medication.
Correct Answer: A
Rationale: The correct answer is A: 'You need to come in for regular blood tests.' Clozapine can cause agranulocytosis, a potentially life-threatening condition, so regular blood tests are required to monitor the client's white blood cell count. Choice B is incorrect because clozapine is associated with weight gain, not weight loss. Choice C is incorrect because the client should never stop taking clozapine abruptly due to the risk of withdrawal symptoms and symptom relapse. Choice D is incorrect because avoiding foods high in tyramine is typically associated with MAOIs, not clozapine.
The nurse documents that a male client with paranoid schizophrenia is delusional. Which statement by the client confirms this assessment?
- A. The voices are telling me to kill the next person I see.
- B. The fire is burning my skin away right now.
- C. The snakes on the wall are going to eat me.
- D. The nurse at night is trying to poison me with pills.
Correct Answer: D
Rationale: The correct answer is D. Believing that the nurse is trying to poison him with pills is a clear indication of delusional paranoia, a common symptom in paranoid schizophrenia. Choices A, B, and C do not directly relate to paranoid delusions and are more indicative of hallucinations or other forms of delusions not specific to paranoia.
Which information should the LPN/LVN exclude in the nursing plan of care for a client with obsessive-compulsive disorder (OCD)?
- A. The medical diagnosis of the client
- B. Individualized goals and objectives
- C. Attendance at group therapy sessions
- D. Self-care measures to improve hygiene
Correct Answer: A
Rationale: The correct answer is A because including the medical diagnosis of the client in the nursing plan is redundant as the healthcare team is already aware of the diagnosis. The nursing plan of care for a client with OCD should focus on individualized goals, objectives, attendance at group therapy sessions, and self-care measures to improve hygiene. These components directly contribute to addressing the client's needs and promoting recovery. Therefore, the medical diagnosis does not need to be included in the nursing plan as it does not actively guide the day-to-day care and interventions for the client.