Nursing Elites

1. A client is admitted to the mental health unit and reports taking extra antianxiety medication because, “I’m so stressed out. I just wanted to go sleep.” The nurse should plan one-on-one observation of the client based on which statement?

• A. What should I do? Nothing seems to help.
• B. I have been so tired lately and needed to sleep.
• C. I really think that I don’t need to be here.
• D. I don’t want to talk. Nothing matters anymore.

Correct answer: D

Rationale: The client's statement of not wanting to talk and feeling that nothing matters anymore is indicative of severe depression or a risk for self-harm. This warrants immediate attention and one-on-one observation to ensure the client's safety. Choices A, B, and C do not express the same level of concerning behavior and do not imply an immediate risk to the client's well-being.

2. A client with post-traumatic stress disorder (PTSD) is struggling with flashbacks and nightmares. Which therapeutic approach should the nurse include in the care plan?

• A. Cognitive-behavioral therapy.
• B. Electroconvulsive therapy (ECT).
• C. Medication management only.
• D. Relaxation training and mindfulness.

Correct answer: A

Rationale: Corrected Question: A client with post-traumatic stress disorder (PTSD) experiencing flashbacks and nightmares would benefit from cognitive-behavioral therapy (CBT) in the care plan. CBT is an evidence-based therapeutic approach that focuses on identifying and changing negative thought patterns and behaviors associated with PTSD symptoms. This helps the client learn coping strategies to manage distressing symptoms like flashbacks and nightmares.\nIncorrect Choices Rationale: B) Electroconvulsive therapy (ECT) is not indicated for PTSD and is typically used for severe depression that has not responded to other treatments. C) Medication management alone may not address the underlying cognitive and behavioral aspects of PTSD. D) Relaxation training and mindfulness can be helpful as adjunctive therapies but may not be as effective as CBT in specifically targeting and modifying PTSD symptoms.

3. A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse’s station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?

• A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril).
• B. Offer the client a prescribed physical therapy hot pack for muscle spasms.
• C. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.
• D. Direct the client to occupational therapy to distract him from somatic complaints.

Correct answer: C

Rationale: The client is experiencing a dystonic reaction due to dopamine depletion, which is a known side effect of Risperidone. Dystonia presents as abnormal muscle contractions and postures. The immediate management for this side effect is the administration of an anticholinergic medication like Benztropine (Cogentin). Choice A is incorrect as thioridazine is not the recommended medication for dystonic reactions. Choice B is incorrect as a hot pack would not effectively address the underlying cause of the dystonic reaction. Choice D is incorrect as occupational therapy is not the appropriate intervention for managing acute dystonia.

4. A teenager who has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the nurse to include in the client plan of care?

• A. Implement behavior modification therapy.
• B. Initiate caloric and nutritional therapy.
• C. Evaluate the client for low self-esteem.
• D. Record daily weights and graph trends.

Correct answer: B

Rationale: Initiating caloric and nutritional therapy is the most important intervention for this client due to the significant weight loss and presenting symptoms of hypotension, tachycardia, irregular menses, and hair loss. This intervention aims to address the physical effects of malnutrition and support the client's overall health. Behavior modification therapy (Choice A) may be beneficial in the long term to address underlying issues, but addressing the immediate nutritional needs is a priority. Evaluating the client for low self-esteem (Choice C) is important for holistic care but addressing the physical health concerns takes precedence. Recording daily weights and graphing trends (Choice D) is essential for monitoring progress but does not address the urgent need for nutritional support in this acute situation.

5. A male client who recently lost a loved one arrives at the mental health center and tells the nurse he is no longer interested in his usual activities and has not slept for several days. Which priority nursing problem should the nurse include in this client’s plan of care?

• A. Risk for suicide
• B. Sleep deprivation
• C. Situational low self-esteem
• D. Social isolation

Correct answer: A

Rationale: The correct answer is A: Risk for suicide. Considering the client's recent loss, lack of interest in activities, and sleep disturbances, the nurse should prioritize assessing and addressing the risk for suicide. This client is displaying warning signs such as loss of interest in usual activities and sleep disturbances, which are commonly associated with suicidal ideation. B: Sleep deprivation is not the priority issue in this scenario, as the client's lack of sleep is likely a symptom of a deeper emotional struggle. C: Situational low self-esteem and D: Social isolation may be concerns for this client but do not take precedence over the immediate risk of suicide, given the presented symptoms.

Similar Questions