A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain to the nursing staff about the client's disruptive behaviors. Which of the following initial actions should the nurse take?

Discuss the problem in a community meeting with the other clients on the unit present.

Escort the client to her room each time the nurse observes the client socializing with other clients.

Talk to the client and identify the specific limits that are required of the client's behavior.

Tell the other clients to ignore the client's lies

Answer and Explanation

The Correct Answer is C

A. Discuss the problem in a community meeting with the other clients on the unit present.

While open communication and community meetings can be valuable in certain situations, discussing a client's disruptive behavior in front of others may breach their privacy and dignity. It's important to address such matters privately and respectfully.

B. Escort the client to her room each time the nurse observes the client socializing with other clients.

This action might be seen as overly punitive and restrictive. Isolating the client based on their behavior without addressing the underlying issues doesn't promote a therapeutic approach to the situation.

C. Talk to the client and identify the specific limits that are required of the client's behavior.

This is the correct option. Talking to the client directly allows the nurse to address the behavior, express expectations, and set clear boundaries. This approach promotes open communication and gives the client a chance to understand how their actions are affecting others.

D. Tell the other clients to ignore the client's lies.

While it's important to encourage other clients to manage their reactions to disruptive behavior, simply telling them to ignore lies might not address the root cause of the issue. The nurse should aim to address the behavior itself and create an environment where all clients feel respected and safe.

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Correct Answer is B

Explanation

A.In the context of severe anxiety, clients might engage in attention-seeking behaviors as a way to express their distress or seek support. However, wild fidgeting remains a more direct and common manifestation of severe anxiety.

B.Severe anxiety can lead to various physical and psychological manifestations. "Wild fidgeting" is a common physical manifestation of severe anxiety. It involves restlessness, rapid movements, and an inability to sit still. Fidgeting can be a way for individuals to release excess energy and manage their heightened anxiety levels.

C.While severe anxiety can lead to a variety of behaviors, threatening behavior is not a typical or direct manifestation of severe anxiety. Such behavior may be more indicative of other mental health issues or agitation.

D.Severe anxiety is more likely to cause impairments in concentration, focus, and problem-solving abilities rather than mild difficulty. Severe anxiety can lead to cognitive overload and make it challenging for individuals to think clearly and solve problems effectively.

A. Speak to the provider about adding an MAOI to the current medication regimen. B. Explain that antidepressants often take several weeks to be fully effective. C. Tell the client that the provider will need to change citalopram to a different medication. D. Recommend a sleep study be done on the client

Correct Answer is B

Explanation

This action might be premature. MAOIs (Monoamine Oxidase Inhibitors) are a class of antidepressants with specific dietary and medication interactions. They are typically considered when other classes of antidepressants have not been effective. It's important to exhaust other options before considering a switch to MAOIs.

B. Explain that antidepressants often take several weeks to be fully effective:

Explanation: Correct Answer. This is an appropriate response. Antidepressants, including citalopram, can take several weeks to show their full therapeutic effects. It's common for some symptoms to improve before others. Educating the client about the delayed onset of action is important to manage their expectations.

C. Tell the client that the provider will need to change citalopram to a different medication:

Explanation: It might be too early to consider changing the medication after just two weeks, especially since the client reports an improved appetite. Changes in dosage or medication should ideally be discussed with the provider after an adequate trial period.

D. Recommend a sleep study be done on the client:

Explanation: While sleep problems can be associated with depression, it might not be the most appropriate next step based solely on the information provided. It's more important to address the ongoing depressive symptoms before focusing solely on sleep.

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A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain to the nursing staff about the client's disruptive behaviors. Which of the following initial actions should the nurse take?

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