An older adult woman who lives in a long-term mental health facility has a history of taking belongings from other clients' rooms when she becomes agitated. The client is found placing these items in the same closet on the unit. Which action should the nurse take?

Tell the client that it is important to respect others' belongings.

Take away privileges until the behavior is extinguished.

Nothing, her action is not harmful to others.

Remove the client from these areas when she is agitated.

Answer and Explanation

The Correct Answer is D

A) Telling the client that it is important to respect others' belongings may be a valid point, but it does not address the immediate behavior and does not provide a practical solution. Simply stating this may not help the client understand the consequences of her actions or modify her behavior.

B) Taking away privileges until the behavior is extinguished can lead to feelings of punishment and may not be effective in changing the behavior. It is essential to approach the situation with understanding rather than punitive measures.

C) Doing nothing is not an appropriate response. While the behavior may not be physically harmful, it can disrupt the community and the therapeutic environment of the facility. It is important to address the behavior proactively.

D) Removing the client from these areas when she is agitated is the most appropriate action. This intervention helps to prevent the behavior from occurring and allows the nurse to manage the client’s agitation in a constructive way. It provides an opportunity to redirect her focus and reduce her agitation, promoting a safer environment for all clients.

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Correct Answer is A

Explanation

A) The statement "It is essential not to abruptly discontinue taking the medication" indicates the client’s awareness of the critical importance of tapering off benzodiazepines like alprazolam to avoid withdrawal symptoms, which can include rebound anxiety, seizures, and other complications. This demonstrates a fundamental understanding of medication safety and the potential risks associated with abrupt discontinuation.

B) Reporting any decrease in anxiety using a 10-point scale is beneficial for monitoring progress but is not as critical as understanding the implications of stopping medication suddenly. This reflects an awareness of managing anxiety but not necessarily the highest priority in self-care.

C) Attending individual and group therapy sessions is important for comprehensive treatment of GAD. However, this statement does not reflect the most immediate self-care concern related to the medication.

D) Reporting dizziness, light-headedness, or sedation shows the client’s awareness of potential side effects, which is important, but again, it does not encompass the crucial self-care goal regarding the safe management of alprazolam.

A. Offer a referral to pastoral counseling. B. Suggest the need for a psychiatric consultation. C. Explore changes in life that have occurred after the loss. D. Encourage attending a local support group.

Correct Answer is C

Explanation

A) Offering a referral to pastoral counseling can be helpful, but it may not address the immediate emotional needs of the client who is experiencing extreme sadness and difficulty controlling emotions. This option can be considered later in the therapeutic process.

B) Suggesting the need for a psychiatric consultation might be appropriate, but it could be premature at this point. The focus should first be on understanding the client’s current emotional state and helping them process their grief.

C) Exploring changes in life that have occurred after the loss is the first and most important action. This approach allows the nurse to facilitate the client’s expression of feelings, which is crucial in the grieving process. By discussing the impact of the loss, the nurse can provide emotional support and help the client begin to process their grief.

D) Encouraging attendance at a local support group can be beneficial, but it may not be the most immediate action. The client needs to be heard and understood in their current emotional state before considering additional resources or support systems.

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An older adult woman who lives in a long-term mental health facility has a history of taking belongings from other clients' rooms when she becomes agitated. The client is found placing these items in the same closet on the unit. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a client for discharge who has been taking alprazolam long-term for generalized anxiety disorder (GAD). When evaluating the client's understanding of the discharge teaching, which statement made by the client shows awareness of the most important self-care goal?

Correct Answer is A

Explanation

The nurse is caring for client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?

Correct Answer is C

Explanation

When responding to a call light, the nurse finds a client with aggressive behaviors pacing and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?

A client with opioid dependence makes a statement to the nurse about desiring to lead a healthier lifestyle by making changes in the next 2 weeks. How should the nurse respond?

The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?

The healthcare provider prescribes lithium carbonate for a client diagnosed with bipolar, manic depression. It is most important for the nurse to review which laboratory finding prior to beginning the drug therapy?

The nurse is assessing a client with postpartum depression for changes in the mood and cognitive state. Which subjective finding(s) should the nurse identify that are consistent with postpartum depression? Select all that apply.

The nurse is admitting a client who has not slept in three days to the inpatient care facility. The client has pressured speech and describes an increase in sexual promiscuity. Which problem should the nurse include in the client's plan of care?