A nurse is caring for a client who was admitted to the facility in critical condition following a cerebrovascular accident.

The client's son says to the nurse, "I wish I could stay, but I need to go home to see how my children are doing. I really hate to leave." Which of the following responses should the nurse make?

"There's nothing you can do here. You should go home to your children."

"You are feeling drawn in two separate directions."

"Perhaps you could call your children to see how they are doing."

"Don't worry.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Dismissive and unsupportive: This response discounts the client's son's feelings of guilt and obligation toward their parent. It also implies that the client's son's presence is not valuable, which could further increase their distress.

Undermines the client's son's role as a caregiver: It suggests that the client's son has no responsibilities or ability to contribute to their parent's care, which could diminish their sense of agency and potentially lead to resentment or regret.

Fails to address the underlying emotions: It does not acknowledge the client's son's internal conflict and emotional turmoil, which is essential for providing effective support.

Choice C rationale:

Offers a practical solution, but may not address the core issue: While calling the children could provide temporary reassurance, it may not fully alleviate the client's son's feelings of guilt or anxiety about leaving their parent.

May not be feasible or sufficient: The client's son may need more than a phone call to feel comfortable leaving, and they may not be able to reach their children immediately.

Could be perceived as dismissive: It could suggest that the nurse is minimizing the client's son's concerns and not fully understanding their emotional needs.

Choice D rationale:

Reassuring, but may not address the client's son's guilt: While it provides assurance about the client's care, it does not directly acknowledge or validate the client's son's feelings of guilt or obligation.

Focuses on the client's care, but not the client's son's needs: It prioritizes the physical care of the client, but may overlook the emotional needs of the client's son, who is also a primary stakeholder in the situation.

May not be enough to alleviate the client's son's concerns: The client's son may still feel responsible for their parent's well- being, even with reassurance from the nurse.

Choice B rationale:

Empathetic and validates the client's son's feelings: It directly acknowledges the client's son's conflicting emotions and demonstrates understanding of their difficult situation.

Promotes self-reflection and exploration: It encourages the client's son to further express their feelings and explore their options, which can lead to greater clarity and self-awareness.

Facilitates decision-making: It helps the client's son to weigh their priorities and make a decision that aligns with their values and responsibilities, ultimately empowering them to take action.

Strengthens the therapeutic relationship: It demonstrates the nurse's ability to connect with the client's son on an emotional level, building trust and rapport.

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Correct Answer is A

Explanation

Choice A rationale:

1. Understanding OCD:

OCD is a chronic mental health condition characterized by intrusive thoughts (obsessions) and repetitive behaviors (compulsions).

Individuals with OCD feel compelled to perform rituals to relieve anxiety or prevent perceived harm, even if they recognize the behaviors as excessive or irrational.

Rituals can consume significant time and interfere with daily functioning.

2. Rationale for Choice A:

Acknowledges the client's needs: Planning for rituals demonstrates understanding and acceptance of the client's experience, fostering trust and rapport.

Reduces anxiety: Allowing time for rituals can temporarily reduce anxiety, making the client more receptive to other interventions.

Gradual approach: It's a stepping stone towards Exposure and Response Prevention (ERP), the gold-standard treatment for OCD.

Enhances control: Scheduling rituals can help the client feel more in control, reducing the urge to engage in them compulsively.

3. Addressing potential concerns:

Reinforcing rituals: While there's a possibility of temporarily reinforcing rituals, it's a necessary first step to build trust and engagement in therapy.

Interfering with treatment: Scheduling rituals is a part of a comprehensive treatment plan that includes ERP and other therapies to address the underlying causes of OCD.

4. Importance of individualized care:

The specific approach to planning for rituals should be tailored to the client's unique needs, preferences, and severity of symptoms.

Collaboration with the client is essential to ensure their active participation in treatment. I'll now address the rationales for the incorrect choices:

Choice B rationale:

Setting strict limits on behaviors can be counterproductive: Triggers anxiety and distress

Impedes trust and therapeutic alliance Diminishes sense of control

Heightens resistance to treatment

Choice C rationale:

Confronting the client about the senselessness of rituals is ineffective and potentially harmful: Exacerbates anxiety and shame

Alienates the client

Disregards the involuntary nature of OCD Undermines motivation for treatment Choice D rationale:

Isolating the client is unethical and detrimental:

Increases distress and loneliness Impedes therapeutic interactions Reinforces negative self-perceptions

Lacks evidence of efficacy in OCD treatment

A. Sweating and fever B. Discolored urine C. Decreased appetite D. Hallucinations.

Correct Answer is A

Explanation

The adverse effect the nurse should report to the provider is A. Sweating and fever.

This combination of symptoms is a key indicator of Serotonin Syndrome, a potentially life-threatening condition that, while rare with buspirone alone, can occur, particularly if the client is taking other medications that increase serotonin (like SSRIs or MAOIs).

The nurse should report these signs immediately because:

Sweating (Diaphoresis) and High Fever (Hyperthermia) are core components of the triad of symptoms for Serotonin Syndrome (autonomic instability).
Serotonin Syndrome also involves changes in mental status (e.g., confusion, hallucinations, which is option D) and neuromuscular hyperactivity (e.g., muscle rigidity, tremors).
This is a medical emergency that requires immediate intervention to prevent complications like rhabdomyolysis, metabolic acidosis, and renal failure.

In comparison:

C. Decreased appetite is a common, generally mild, and manageable side effect.
D. Hallucinations are a serious central nervous system side effect, but when presented alongside the life-threatening systemic signs of Serotonin Syndrome (A), option A represents the more urgent and dangerous adverse reaction.
B. Discolored urine is not a standard adverse effect and would need investigation, but is not as acutely critical as signs of Serotonin Syndrome.

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Naxlex Comprehensive Predictor Exams

A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the mental health nurse plan to take regarding the client's compulsive behaviors?

Correct Answer is A

Explanation

A nurse is caring for a client who has generalized anxiety disorder and is taking buspirone. Which of the following adverse effects should the nurse report to the provider?

Correct Answer is A

Explanation

A nurse in a hospital is caring for a client who has agoraphobia. Which of the following statements by the client indicates understanding of the goals of treatment?

A nurse is caring for a client who has a mental illness.Which of the following actions by the nurse demonstrates the ethical concept of autonomy?

A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat.Which of the following aspects of care should the nurse consider the first priority for this client?

A nurse is caring for a client in the emergency department (ED). The client comes to the ED via ambulance. The client has a history of bipolar disorder and is experiencing acute mania. Select the 3 prescriptions that the nurse should anticipate for this client.

A nurse is preparing to administer fluoxetine 40 mg PO daily. The amount available is fluoxetine 20 mg/5mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies.Do not use a trailing zero.).