Mario is admitted to the emergency room with drug-included anxiety related to over ingestion of prescribed antipsychotic medication. The most important piece of information the nurse in charge should obtain initially is the:
-
Solution
Name of the ingested medication & the amount ingested
Option B: In an emergency, lives saving facts are obtained first. The name and the amount of medication ingested are of utmost important in treating this potentially life threatening situation.
Nurse Tina is caring for a client with depression who has not responded to antidepressant medication. The nurse anticipates that what treatment procedure may be prescribed?
-
Solution
Electroconvulsive therapy
Option D: Electroconvulsive therapy is an effective treatment for depression that has not responded to medication.
When planning the discharge of a client with chronic anxiety, Nurse Chris evaluates achievement of the discharge maintenance goals. Which goal would be most appropriately having been included in the plan of care requiring evaluation?
-
Solution
The client identifies anxiety-producing situations
Option C: Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid specific stimulus.
During electroconvulsive therapy (ECT) the client receives oxygen by mask via positive pressure ventilation. The nurse assisting with this procedure knows that positive pressure ventilation is necessary because?
-
Solution
Muscle relaxations given to prevent injury during seizure activity depress respirations.
Option D: A short-acting skeletal muscle relaxant such as succinylcholine (Anectine) is administered during this procedure to prevent injuries during seizure.
Nurse Jonel is providing information to a community group about violence in the family. Which statement by a group member would indicate a need to provide additional information?
-
Solution
“Abuse occurs more in low-income families”
Option A: Personal characteristics of abuser include low self-esteem, immaturity, dependence, insecurity and jealousy.
Nurse Tina is caring for a client with delirium and states that “look at the spiders on the wall”. What should the nurse respond to the client?
-
Solution
“I know you are frightened, but I do not see spiders on the wall”
Option D: When hallucination is present, the nurse should reinforce reality with the client.
Nurse Nina is assigned to care for a client diagnosed with Catatonic Stupor. When Nurse Nina enters the client’s room, the client is found lying on the bed with a body pulled into a fetal position. Nurse Nina should…
-
Solution
Sit beside the client in silence and occasionally ask open-ended question
Option C: Clients who are withdrawn may be immobile and mute, and require consistent, repeated interventions. Communication with withdrawn clients requires much patience from the nurse. The nurse facilitates communication with the client by sitting in silence, asking open-ended question and pausing to provide opportunities for the client to respond.
A male client who is experiencing disordered thinking about food being poisoned is admitted to the mental health unit. The nurse uses which communication technique to encourage the client to eat dinner?
-
Solution
Using open-ended question and silence
Option B: Open-ended questions and silence are strategies used to encourage clients to discuss their problem in a descriptive manner.
A long-term goal for a paranoid male client who has unjustifiably accused his wife of having many extramarital affairs would be to help the client develop:
-
Solution
Feeling of self-worth
Option C: Helping the client to develop feeling of self-worth would reduce the client’s need to use pathologic defenses.
A 23-year-old client has been admitted with a diagnosis of schizophrenia says to the nurse “Yes, its march, March is little woman”. That’s literal you know”. These statements illustrate:
-
Solution
Loosening of association
Option D: Loose associations are thoughts that are presented without the logical connections usually necessary for the listening to interpret the message.