Therapeutic Communication
During admission, a very anxious client worries that the sun won't rise tomorrow. What is the RN's best initial approach?
What is Remain calm, matter-of-fact?
Which finding shows improvement in a depressed client after 2 weeks of antidepressants?
What is an improvement in doing things they were avoiding ex: Initiates interaction with peers
A schizophrenic client insists food is poisoned. Which intervention is best?
What is provide food in unopened containers?
Safety planning for intimate partner violence includes all EXCEPT:
What is Purchase a gun to use for protection?
Client with alcohol withdrawl begins halluncinating. Which PRN is best?
What is Lorazepam (Ativan)?
A client hears voices commanding self-harm. What is the nurse's priority intervention?
What is SAFETY, and Acknowledge that you do not hear the voices, and don't allow access to harmful objects?
Which intervention best supports a client with psychomotor retardation and hypersomnia?
What is a Structured daily activity plan?
A client with echolalia is disrupting peers. What's the nurse's best action?
What is escort to a private room?
Which lab is the most concerning in a client on lithium?
What is Sodium level?
What vitamins should the nurse administer for a client in alcohol detox?
What is Thimine (Vitamin B1), Folate (Folic Acid) both are Vitamin B9, Vitamin B12 (Cobalamin)
When interviewing a new client, which environmental adjustment best supports the interview?
What is creating a quiet and calm environment ex: Reduce noise by turning off the TV
Which client statement reflects projection?
A. "I am here because the police thought I was doing something wrong."
B. "At least I hit the wall instead of hitting the psychiatric aide."
C. "I want to be here because I know it is the best psychiatric facility."
D. "Don't believe everything my family tells you. I am not crazy."
What is A. "I am here because the police thought I was doing something wrong."
A client tells the nurse that he is an accomplished writer and that directors of television shows contact him for suggestions on actors and locations. The nurse realizes this client is experiencing the delusion of
What is Grandosity?
A client on olanzapine (Zyprexa) is at risk for which adverse effect?
What is Severe weight gain?
Disulfiram (Antabuse) education: What is the most important thing to inform patients about this medication?
What is refrain from alcohol use?
A client states, 'Don't believe everything my family tells you-I'm not crazy.' This reflects which defense mechanism?
What is Projection?
A college student with anxiety after a carjacking, what is the nurse's priority?
What is to help the client feel safe, i.e., SAFETY?
A client claims that voices are talking to her and telling her to do things. Which type of hallucination is this?
What is Command hallucinations?
A client on haloperidol develops tremors. Which intervention is best?
A) Give more haloperidol
B) Contact HCP about reducing dose
C) Ignore, it will pass
D) Stop medication immediately
What is Contact HCP about reducing dose?
Rationale: This is the safest action, as dose reduction or adding an anticholinergic (like benztropine) is usually indicated. Stop medication immediately → Wrong, abrupt discontinuation is unsafe and not within nursing scope without HCP direction.
A long-term alcoholic complains of severe abdominal pain-what condition should the nurse suspect?
What is Pancreatitis?
When a client's agitation escalates, what should the nurse do first?
What is remove other clients from the area or remove the client from the area?
A client with anorexia nervosa presents with tachycardia, hypotension, and irregular menses. What's the priority intervention?
Assess vital signs, then stabilize medically, Correct dehydration, and electrolyte imbalances. Ensure safety
A borderline client with self-inflicted cuts requires a dressing change. The best approach for the nurse to take is judgmental or non-judmental?
What is non-judmental?
Antidepressant side effects (SATA):
A) Constipation
B) Headache
C) Blurred Vision
D) Dry Mouth
What is Constipation, Blurred Vision, and Dry Mouth?
A client with PTSD should be placed:
What is in a quiet, safe environment?