A nurse is reviewing the medical records of four clients. Which of the following findings should the nurse identify as a risk factor for violent behavior?

Long-term isolation

Dysthymic disorder

Alcohol intoxication

Schizoid personality disorder

Answer and Explanation

The Correct Answer is C

A. Long-term isolation: Long-term isolation, or social isolation, can lead to feelings of loneliness and depression. While prolonged isolation can contribute to mental health issues, it is not a direct risk factor for violent behavior. People who are socially isolated might suffer from emotional distress, but it doesn't necessarily make them violent.

B. Dysthymic disorder: Dysthymic disorder, also known as persistent depressive disorder, is a type of chronic depression. While individuals with dysthymic disorder may experience low moods and a lack of interest in activities, it doesn't inherently make them prone to violence. Depression is more likely to cause self-directed harm (such as self-harm or suicide) rather than violent behavior towards others.

C. Alcohol intoxication: Alcohol is a substance that impairs judgment and reduces inhibitions. When a person is intoxicated, they may act aggressively or violently, even in situations where they wouldn't normally do so. Alcohol intoxication can lead to a loss of control, impaired decision-making, and aggressive behavior, making it a significant risk factor for violent actions.

D. Schizoid personality disorder: Schizoid personality disorder is characterized by a lack of interest in social relationships, emotional coldness, and detachment. While individuals with this disorder may prefer to be alone and avoid social interactions, they are not necessarily prone to violent behavior. Schizoid personality disorder primarily affects social functioning rather than predisposing someone to violence.

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Correct Answer is C

Explanation

A. Prepare the client for electroconvulsive therapy:
Electroconvulsive therapy (ECT) is not a standard or appropriate treatment for anorexia nervosa. ECT is primarily used for severe depression, bipolar disorder, and certain other mental health conditions. Anorexia nervosa is typically managed through psychotherapy, nutritional counseling, and medical monitoring, often in an outpatient or inpatient setting, depending on the severity of the disorder.

B. Weigh the client twice per day:
Frequent weighing is generally discouraged in the treatment of anorexia nervosa. Individuals with this disorder often have an unhealthy fixation on their weight. Frequent weigh-ins can exacerbate anxiety, foster an unhealthy relationship with food and body image, and reinforce obsessive thoughts about weight and appearance. Healthcare providers should monitor weight and nutritional status regularly, but the frequency should be determined based on the individual's specific needs and in a manner that does not worsen their anxiety.

C. Encourage the client to participate in family therapy:
This is the appropriate choice. Family therapy is often a crucial component of the treatment plan for anorexia nervosa. It helps address family dynamics, communication patterns, and any dysfunctional relationships that might contribute to the eating disorder. Family therapy provides a supportive environment for both the individual with anorexia and their family members, aiding in understanding, coping, and healing.

D. Set a weight gain goal of 2.2 kg (4.9 lb) per week:
Setting specific weight gain goals can be counterproductive and potentially harmful for individuals with anorexia nervosa. Rapid or arbitrary weight gain goals may lead to unhealthy eating behaviors, excessive exercise, or other dangerous practices in an attempt to meet the goal quickly. Instead, healthcare providers focus on a more individualized and gradual approach to weight restoration, ensuring that it is safe, sustainable, and in line with the client's overall health and well-being.

A. Instruct the client to consume a low-sodium diet to decrease hand tremors. B. Teach the client to take the lithium in a single daily dose C. Contact the provider for a possible decrease in the lithium dosage. D. Encourage the client to take naproxen sodium to decrease tremors.

Correct Answer is C

Explanation

A. Instruct the client to consume a low-sodium diet to decrease hand tremors:
While maintaining a stable sodium intake is important for individuals taking lithium to avoid fluctuations in lithium levels, a low-sodium diet is not specifically indicated to address hand tremors caused by lithium. Adjusting sodium levels is more about maintaining a consistent intake to stabilize lithium levels over time.

B. Teach the client to take the lithium in a single daily dose:
Lithium is often prescribed in divided doses to maintain stable blood levels throughout the day and minimize side effects. However, the dosing regimen (once or multiple times a day) is usually determined by the healthcare provider based on the individual's needs. Changing the dosing frequency is not the primary intervention for managing hand tremors.

C. Contact the provider for a possible decrease in the lithium dosage:
Hand tremors are a common side effect of lithium. If a client is experiencing bothersome side effects within the therapeutic range, the appropriate action is to contact the healthcare provider. The provider can assess the situation, possibly adjust the dosage, or explore other management options to alleviate the tremors while maintaining the therapeutic effect of the medication.

D. Encourage the client to take naproxen sodium to decrease tremors:
Encouraging the client to take naproxen sodium or any other nonsteroidal anti-inflammatory drug (NSAID) is not recommended when the client is on lithium therapy. NSAIDs can interact with lithium, potentially leading to increased lithium levels and toxicity. Combining these medications should be avoided.

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A nurse is reviewing the medical records of four clients. Which of the following findings should the nurse identify as a risk factor for violent behavior?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

A nurse in a community mental health clinic is assessing a client who began taking lithium carbonate 5 days ago. The client reports fine hand tremors and has a current lithium level of 1.2 mEq/L. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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