A nurse on an inpatient mental health unit is caring for a client.

Exhibits

The nurse is discussing the assessment findings on day 3 of admission during the 1900 change of-shift report. For each finding, specify whether the finding indicates potential improvement in or worsening of the client’s condition.

Giving away car

Hygiene

Food intake

Condition of skin on right hand

Rapid change in mood

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Indicates potential Improvement a. Hygiene b. Food intake c. Rapid change in mood

Indicates potential worsening a. Giving away car b. Condition of skin on right hand

Choice A: Giving away car

This could be a sign of the client’s worsening condition. Giving away possessions can sometimes be a sign of suicidal ideation. It’s important to monitor this behavior and report it to the healthcare provider.

Choice B: Hygiene

The client showered without prompting on the third day, which is an improvement from the first day when they declined to shower. Improved personal hygiene can be a sign of improvement in a client with obsessive-compulsive disorder.

Choice C: Food intake

The client ate 75% of their meals on the third day, which is an improvement from the first day when they refused to eat. Increased food intake can indicate an improvement in the client’s condition2.

Choice D: Condition of skin on right hand

The client’s hands remain reddened with a 1 cm x 1 cm area of peeling skin noted on the center of the right palm. This could indicate a worsening condition, as it may be a result of excessive handwashing, a common compulsion in OCD.

Choice E: Rapid change in mood

The client’s affect rapidly changed throughout the afternoon and early evening; the client is now talkative and appears content. This could indicate an improvement in the client’s condition, as they are engaging more with others and showing more positive emotions.

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Correct Answer is A

Explanation

Choice A reason: Donepezil is often administered before bedtime to reduce the risk of nausea, which is a common side effect. Taking it at bedtime can also coincide with the body's natural rest period, potentially minimizing the impact of any side effects.

Choice B reason: Alzheimer's disease is a progressive condition, and currently, there is no cure. The provider will not decrease the dose as the disease improves because the disease typically worsens over time. Medication management may change, but it is based on symptom control, not improvement of the disease.

Choice C reason: Donepezil does not stop the progression of Alzheimer's disease. It can help manage symptoms and improve quality of life, but it does not cure or halt the disease's progression.

Choice D reason: Donepezil does not decrease the risk of falls. In fact, some of its side effects, such as dizziness, may increase the risk of falls. It is important for caregivers to monitor their partners for such side effects and take precautions to prevent falls.

A. Tell the client that their experience is not real. B. Avoid asking direct questions about the client's experience. C. Focus the client on reality-based activities. D. Convey sympathy for the client's experience.

Correct Answer is C

Explanation

Choice A reason: Telling a client that their experience is not real can be invalidating and may damage the therapeutic relationship between the nurse and the client. It is essential to acknowledge the client's experience as real to them and provide support without reinforcing the hallucination.

Choice B reason: While it is important not to reinforce hallucinations, avoiding direct questions about the client's experience can hinder the nurse's ability to assess the client's condition fully. It is better to ask open-ended questions that allow the client to describe their experience without feeling judged.

Choice C reason: Focusing the client on reality-based activities can help distract them from the hallucinations and ground them in the present moment. Activities such as listening to music, engaging in conversation, or participating in a physical activity can help reduce the intensity of hallucinations and provide a sense of control.

Choice D reason: Conveying sympathy for the client's experience is compassionate and can help build trust. However, it is crucial to balance empathy with encouragement to engage in reality-based activities and strategies to manage the hallucinations effectively.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to the partner of a client who has Alzheimer's disease and a new prescription for donepezil. Which of the following pieces of information should the nurse include?

Correct Answer is A

Explanation

A nurse is caring for a client who is experiencing active auditory hallucinations. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who is taking lithium and reports experiencing lethargy, muscle weakness, and blurred vision. Which of the following responses should the nurse make?

A nurse is assessing the sleep pattern of a client who has an anxiety disorder. The client reports having difficulty sleeping most nights. Which of the following recommendations should the nurse make?

Exhibits A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse report to the provider? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)

A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as countertransference?

A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is caring for a client who states, "I am too embarrassed to tell anyone what I did last night." Which of the following responses should the nurse make?

A nurse in a rehabilitation center is caring for a client who has bipolar disorder. Which of the following actions by the client indicates mania?