Mental health, Analgesics

Question 1

An 87-year-old client has been admitted to the hospital with signs and symptoms of a urinary tract infection along with agitation, confusion, and disorientation to time and place. What is the most important nursing action?

1. Encouraging frequent fluid intake
2. Keeping the bed elevated with the side rails raised
3. Providing one on one supervision
4. Turning lights off in client’s room to reduce stimulation

Answer 1

3. Providing one on one supervision

The client’s most immediate needs are safety and prevention of physical injury.

Initially, the client should be placed in a room near the nurses’ station with one-on-one supervision and frequent reorientation to time, place, and situation.

Question 2

A client is newly prescribed extended-release oxycodone 40 mg orally, scheduled every 12 hours to treat severe chronic cancer pain. Which information is most important to reinforce to the client’s caregiver?

1. Admin the med around the clock even if the client denies having pain
2. Avoid administering with immediate release opioids to prevent respiratory depression
3. Change the dosage and frequency to 20 mg 6 hrs if breakthough pain occurs
4. Request a tapered dose form the HCP if pain decreases to prevent tolerance

Answer 2

1. Admin the med around the clock even if the client denies having pain

The nurse should teach the client’s caregiver to administer extended-release oxycodone as scheduled, even if the client does not report pain. Administration twice daily is necessary to maintain a therapeutic level and provide continuous relief as the duration of the analgesic effect is 12 hours.

Option 2: Immediate release opioids + long acting opioids is okay, though respiratory depression should be monitored.

Question 3

A client with schizophrenia says to the nurse, “The world turns as the world turns on a ball at the beach. But all the world’s a stagecoach and I took the bus home.” The nurse recognizes this statement as an example of which of the following?

1. Concrete thinking
2. Loose associations
3. Tangentiality
4. Word salad

Answer 3

2. Loose associations

The rapid shifting from one idea to another, with little or no connection to logic or rationality (Option 2)

Concrete thinking – literal interpretation of an idea; the client has difficulty with abstract thinking. Example: The phrase, “The grass is always greener on the other side,” would be interpreted to mean that the grass somewhere else is literally greener (Option 1).

Tangentiality – going from one topic to the next without getting to the point of the original idea or topic (Option 3)

Word salad – a mix of words and/or phrases having no meaning except to the client. Example: “Here what comes table, sky, apple.” (Option 4)

Question 4

The nurse in the emergency department is caring for a client at 10 weeks gestation who reports being abused by her spouse but is not ready to leave the relationship. Which of the following interventions are appropriate?

Select all that apply.

1. Advise client to avoid triggering the spouse’s behavior
2. Assess the client for thoughts of self-harm
3. Collaborate with the health care team to develop a safety plan
4. Document the client’s injuries on a body map
5. Encourage the client to live with a relative for the duration of the pregnancy

Answer 4

Answer: 2, 3, 4

The nurse should work closely with survivors of IPV to ensure their safety in the event of escalating violence. Appropriate interventions include the following:

Assess the client for thoughts of self-harm because the client may view suicide as the only way out of the relationship (Option 2).

Collaborate with the health care team to develop a safety plan, which facilitates rapid escape from escalating violence.
Components of a safety plan include a secure location to reside and an emergency kit with essential items (Option 3).

Follow facility guidelines for reporting, documenting, gathering evidence, and/or photographing injuries. Thorough documentation of details of the injury on a body map will be needed to facilitate any legal proceedings (Option 4).

Identifying which client behaviors trigger the abuse places blame on the client rather than the abuser. The client is not responsible for the abuse (Option 1)

Unless the client expresses desire to leave the relationship, advising the client to live with a relative is not appropriate (Option 5)

Question 5

A nurse is caring for a client who has tested positive for amphetamines and is experiencing paranoia. The client has a history of physical violence. Which intervention should the nurse implement at this time to prevent the client from becoming violent?

1. Administer prescribed PRN lorazepam and apply soft wrist restraints
2. Explain all activities of care clearly and calmly while facing the client
3. Place the client in the room that is closest to the client’s nurses’ station
4. Request security personnel to be present to protect clients and staff

Answer 5

2. Explain all activities of care clearly and calmly while facing the client

Nursing interventions that help prevent violence include using clear, thorough communication (Option 2); encouraging active participation in care; promoting a low-stimulation environment; and providing comfort through pharmacological and nonpharmacological methods.

Pharmacological and physical restraints should be used last (Option 1)

Placing client near the nurse’s station increase anxiety due to noise (Option 3)

Security personnel does not prevent violence, it may increase client’s anxiety (Option 4)

Question 6

The nurse is providing care to a client experiencing posttraumatic stress disorder following a terrorist attack at the client’s place of worship. What is the priority nursing action?

1. Acknowledge the client’s feelings of anger
2. Assess the client’s support system
3. Encourage client to talk about trauma
4. Offer the client a PRN sleep med

Answer 6

3. Encourage client to talk about trauma

The first step toward resolution of posttraumatic stress disorder (PTSD) is the client’s readiness (ability and willingness) to discuss the details of the traumatic event without experiencing high levels of anxiety. (Option 3)

It is important to acknowledge any feelings that the client may have about the trauma; the priority nursing action is to encourage the client to talk about the event. (Option 1 - I picked this one)

Question 7

The nurse is caring for a new mother whose infant has been diagnosed with Down syndrome. The client says to the nurse, “I’m so worried. My husband is so devastated that he won’t even look at the baby.” What is the best response by the nurse?

1. Both of you will benefit from supportive counseling
2. How are you feeling about your baby?
3. I will have the doctor speak to your husband
4. Why do you think your husband feels this way?

Answer 7

2. How are you feeling about your baby?

When helping the family cope with the crisis, the nurse needs to keep the lines of communication open and offer support. The nurse should use open-ended therapeutic communication techniques that encourage the family members to verbalize what they are feeling or experiencing (Option 2).

(Option 4 - I picked) This is accusatory and nontherapeutic. The nurse should avoid asking “why” questions when attempting to gain more information.