Nursing Elites

1. A young adult male client is admitted to the psychiatric unit because of a recent suicide attempt. His wife filed for divorce six months ago, he lost his job three months ago, and his best friend moved to another city two weeks ago. Which intervention should the nurse include in the client's plan of care?

• A. Encourage the client to interact with individuals who are recovering from depression.
• B. Allow the client time alone to sort out his feelings.
• C. Avoid discussing topics that upset the client.
• D. Encourage activities that allow the client to exert control over his environment.

Correct answer: D

Rationale: Encouraging activities that allow the client to exert control over his environment can be therapeutic in cases of depression and stress. It helps improve the client's sense of agency, which is essential for promoting feelings of empowerment and self-worth. Choice A could potentially be overwhelming for the client, especially considering his recent suicide attempt and ongoing stressors. Choice B might not be the most beneficial intervention as isolation could further exacerbate feelings of loneliness and hopelessness. Choice C, avoiding discussing upsetting subjects, may prevent the client from addressing and processing his emotions, hindering therapeutic progress.

2. A female client with major depression is prescribed fluoxetine (Prozac). She reports experiencing increased energy but still feels sad and hopeless. What is the nurse's best response?

• A. ''These feelings are normal and will pass with time.''
• B. ''Increased energy can sometimes lead to increased risk for self-harm.''
• C. ''The medication needs more time to be effective.''
• D. ''Let's talk about the things that make you feel this way.''

Correct answer: B

Rationale: The correct answer is B. Increased energy without improvement in mood can increase the risk of self-harm in clients with depression. It is crucial for the nurse to recognize this potential risk and closely monitor the client for any signs of self-harm. Choice A is incorrect because dismissing the client's persistent feelings of sadness and hopelessness as normal may invalidate her experiences. Choice C is incorrect as fluoxetine (Prozac) typically starts showing effectiveness within a few weeks, so further delay is concerning. Choice D is incorrect because while discussing the client's feelings is important, the immediate focus should be on addressing the potential risk of self-harm associated with increased energy.

3. A client with a diagnosis of schizophrenia is prescribed risperidone (Risperdal). Which statement by the client indicates a need for further teaching?

• A. I can stop taking this medication once I feel better.
• B. I need to avoid foods that are high in tyramine.
• C. I should avoid drinking alcohol while taking this medication.
• D. This medication may cause drowsiness, so avoid driving.

Correct answer: A

Rationale: The correct answer is A. The statement 'I can stop taking this medication once I feel better' indicates a need for further teaching. Antipsychotic medications, like risperidone, should be taken consistently even when symptoms improve to prevent relapse. Choice B is incorrect because avoiding foods high in tyramine is unrelated to risperidone. Choice C is incorrect as avoiding alcohol is a standard precaution with many medications. Choice D is incorrect because being cautious about drowsiness and avoiding driving is a common safety measure associated with risperidone.

4. A client with obsessive-compulsive disorder (OCD) spends hours checking and rechecking the locks on the doors. What is the best nursing intervention?

• A. Allow the client to continue the behavior to reduce anxiety.
• B. Encourage the client to discuss the thoughts and feelings behind the behavior.
• C. Prevent the client from checking the locks to break the cycle.
• D. Schedule specific times for the client to check the locks.

Correct answer: B

Rationale: The best nursing intervention for a client with OCD who spends excessive time checking locks is to encourage the client to discuss the thoughts and feelings behind the behavior. By exploring the underlying anxiety and triggers, the client can gain insight and work towards behavior modification. Choice A is incorrect because enabling the behavior does not address the underlying issues. Choice C is incorrect as it may lead to increased anxiety and distress. Choice D is incorrect as it does not address the root cause of the behavior.

5. A client with schizophrenia is being treated with haloperidol (Haldol) and begins to exhibit symptoms of tardive dyskinesia. What is the nurse's priority action?

• A. Continue the medication and monitor for worsening symptoms.
• B. Administer the next dose of haloperidol with food.
• C. Report the symptoms to the healthcare provider immediately.
• D. Educate the client about the side effects of haloperidol.

Correct answer: C

Rationale: The correct answer is to report the symptoms to the healthcare provider immediately. Tardive dyskinesia is a serious side effect of antipsychotic medications, including haloperidol. Prompt reporting is crucial to evaluate the need for medication adjustment or change in treatment. Continuing the medication without intervention (choice A) can worsen the symptoms. Administering the next dose (choice B) is not appropriate when tardive dyskinesia is suspected. Educating the client (choice D) is important but not the priority when dealing with acute symptoms of tardive dyskinesia.

Similar Questions