A nurse is caring for a client in a mental health facility. the nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take?
A) Confront the staff
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A nurse is caring for a client in a mental health facility. the nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take?
A) Confront the staff member.
B) Encourage the client to report the incident.
C) Document the incident in the client's health record.
D) Report the occurrence to the charge nurse.
Answer: D It is the charge nurse and the nurse manager's responsibility to confront the staff member about her behavior toward the client.
A nurse is caring for a client who has attempted suicide and has alcohol use disorder. Which of the following statements indicates that the client is using a positive coping mechanism?
A) "I will limit my drinking to the weekends."
B) "I will stay in my room and avoid others when I'm feeling down."
C) "I will be dependent on others for the time being."
D) "I will attend daily group therapy sessions to practice relaxation techniques."
Answer: D Relaxation techniques decreases the risk for self-harm by decreasing stress, anxiety, and depression.
A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan of care?
A) Encourage the client to participate in group therapy.
B) Instruct the client to avoid napping during the day.
C) Offer the client high-calorie finger foods frequently.
D) Decrease the client's daily fiber intake.
Answer: C The nurse should frequently offer the client, high-calorie foods that can be eaten while on the go. Clients experiencing mania might be unable to sit down for meals and can experience weight loss and dehydration.
A nurse is providing teaching to a client who is to begin undergoing light therapy at home to treat seasonal affective disorder. Which of the following should the nurse include in the teaching?
A) Have a family member present during treatment.
B) Increase fluid intake.
C) Change position slowly.
D) Wear sunglasses when outdoors.
Answer: D Light therapy, or phototherapy, can cause eye strain and sensitivity to light.
A nurse in a community health center is teaching families of clients who have posttraumatic stress disorder (PTSD) about expected clinical manifestations. Which of the following manifestations should the nurse include?
A) Repeatedly talks about the traumatic episode.
B) Sleeps excessively.
C) Experiences feelings of isolation.
D) Uses repetitive speech.
Answer: C Clients who have PTSD often feel estranged and detached from others.
A nurse is creating a plan of care for a client who has been in seclusion after threatening to harm others on the unit. Which of the following interventions should the nurse include in the plan?
A) Document the client's behavior every 8 hours.
B) Limit the client's fluid intake to 50 mL/hr.
C) Renew the prescription for the client every 4 hours.
D) Toilet the client every 4 hours.
Answer: C The nurse should assess the client's behavior frequently during seclusion and should renew the prescription for seclusion for an adult client every 4 hours for a maximum of 24 hours.
A nurse is planning prevention strategies for intimate partner abuse in the community. Which of the following strategies should the nurse include as a method of secondary prevention?
A) Provide teaching about the use of positive coping mechanisms.
B) Establish screening programs to identify at-risk clients.
C) Refer survivors of intimate partner abuse to legal advocacy program.
D) Organize rehabilitation therapy for clients who have experienced intimate partner abuse.
Answer: B This is an example of secondary prevention. By establishing screening programs, the nurse can identify individuals who are at risk for intimate partner abuse in the community and can take the necessary steps to address individual client needs.
A nurse in an outpatient mental health setting is collecting a health history from a client who is taking paroxetine for depression. The client reports to the nurse that he also takes herbal supplements. The nurse should advise the client that which of the following supplements interacts adversely with paroxetine?
A) St. John's Wort
B) Saw palmetto
C) Echinacea
D) Ginkgo
Answer: A St. John's Wort is an herbal preparation that decreases the reuptake of serotonin. The nurse should advise the client that taking St. John's Wort with another medication that also inhibits the reuptake of serotonin, such as paroxetine, places the client at risk for serotonin syndrome.
A nurse is planning care for an adolescent who is being admitted to an acute care unit following a suicide attempt. Which of the following interventions should the nurse identify as the priority?
A) Arrange one-to-one observation of the client.
B) Encourage interaction with the client's peers.
C) Administer medication for depressive disorder.
D) Encourage the client to attend a support group.
Answer: A The greatest risk to the client is self-injury. Therefore, the priority nursing intervention is one-to-one observation to promote client safety.
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