A nurse is contributing to the plan of care for a client who has borderline personality disorder and exhibits manipulative behaviors. Which of the
... [Show More] following interventions should the nurse include in the plan to address limit setting?
Establish and explain consequences for the client's behavior
Teach the client to use reaction formation for Behavior control
Recommend that the client attend assertiveness training
Encourage the client to increase socialization
(Ans- Establish and explain consequences for the client's behavior.
The nurse should communicate desired behavior and expectations as well as detailed consequences for not meeting those expectations to a client who has borderline personality disorder. These expectations and consequences should be included in the plan of care when addressing limit setting with the client.
A nurse is assisting with screening a group of clients for major depressive disorder (MDD). The nurse should identify that which of the following clients is at an increased risk for the development of MDD?
A client who is newly employed
A client who abstains from alcohol
A client who just gave birth
A client who has been married for 15 years
(Ans- A client who just gave birth
Clients who just gave birth or are in the early postpartum period are at an increased risk for developing MDD or postpartum depression.
A nurse in a mental health facility is collecting data from a client who has schizophrenia. The nurse should identify that which of the following findings is referred to as a negative symptom of schizophrenia?
Delusions
Echolalia
Apathy
Paranoia
(Ans- Apathy
Negative symptoms of schizophrenia are deficits in the client's ability to experience emotions. Apathy is a negative symptom of schizophrenia that is manifested by a loss of interest in one's surroundings.
A nurse is monitoring the nutritional status of a client who has bulimia nervosa. The nurse should monitor the client for which of the following complications?
Hyperchloremia
Hyponatremia
Decreased bone density
Increased WBC count
(Ans- Hyponatremia
The nurse should monitor clients who have bulimia nervosa for hyponatremia, which results from purging, vomiting, and laxative and/or diuretic use
A nurse is reinforcing teaching with the parent of a child who has ADHD and is exhibiting disruptive behaviors at home. Which of the following actions should the nurse instruct the parent to take?
Avoid enforcing a strict schedule for the child at home.
Use biofeedback with the child.
Give the child a PRN dose of methylphenidate.
Initiate a point system for the child
(Ans- Initiate a point system for the child
The nurse should instruct the parent to use tokens or points to reward desired behaviors and reduce maladaptive behaviors. A point system provides an incentive for the child to increase acceptable behaviors
A nurse is collecting data from a client who has major depressive disorder. Which of the following findings is the priority for the nurse to report to the provider.
Inability to make decisions
Anhedonia
Feelings of hopelessness
Fatigue
(Ans- Feelings of hopelessness
When using the urgent vs. nonurgent approach to client care, the nurse should identify that feelings of hopelessness indicate that this client is at risk for suicide. Therefore, this is the priority finding for the nurse to report to the provider
A nurse in a mental health facility is caring for a client who is becoming agitated. Which of the following actions should the nurse take first?
Please the client in seclusion
Offer a diversionary activities
Administer haloperidol
Apply wrist restraints
(Ans- Offer a diversionary activities
When providing client care, the nurse should first use the least restrictive intervention. Therefore, the nurse should offer diversionary activities to distract the client and redirect their energy into more appropriate behaviors
A nurse is reinforcing teaching about expected withdrawal manifestations with a client who has enrolled in a smoking cessation course. Which of the following client statement indicates an understanding of the information?
"I can expect my cigarette cravings to go away within 7 to 10 days."
"I will likely feel like my heart is racing even when I'm resting."
"I should increase my intake of calories because of the expected weight loss."
"I will probably feel irritable within 24 hours of my last cigarette."
(Ans- "I will probably feel irritable within 24 hours of my last cigarette." [Show Less]