A nurse on an inpatient mental health unit is caring for a client.

Exhibits

The nurse is discussing the assessment findings on day 3 of admission during the 1900 change of-shift report. For each finding, specify whether the finding indicates potential improvement in or worsening of the client’s condition.

Giving away car

Hygiene

Food intake

Condition of skin on right hand

Rapid change in mood

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Indicates potential Improvement a. Hygiene b. Food intake c. Rapid change in mood

Indicates potential worsening a. Giving away car b. Condition of skin on right hand

Choice A: Giving away car

This could be a sign of the client’s worsening condition. Giving away possessions can sometimes be a sign of suicidal ideation. It’s important to monitor this behavior and report it to the healthcare provider.

Choice B: Hygiene

The client showered without prompting on the third day, which is an improvement from the first day when they declined to shower. Improved personal hygiene can be a sign of improvement in a client with obsessive-compulsive disorder.

Choice C: Food intake

The client ate 75% of their meals on the third day, which is an improvement from the first day when they refused to eat. Increased food intake can indicate an improvement in the client’s condition2.

Choice D: Condition of skin on right hand

The client’s hands remain reddened with a 1 cm x 1 cm area of peeling skin noted on the center of the right palm. This could indicate a worsening condition, as it may be a result of excessive handwashing, a common compulsion in OCD.

Choice E: Rapid change in mood

The client’s affect rapidly changed throughout the afternoon and early evening; the client is now talkative and appears content. This could indicate an improvement in the client’s condition, as they are engaging more with others and showing more positive emotions.

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Correct Answer is C

Explanation

Choice A reason: Ringing in the ears is not a common side effect of lorazepam. This medication is more likely to cause drowsiness or dizziness, which could increase the risk of falls.

Choice B reason: Restraints should only be used as a last resort when all other options have been exhausted and the client is a danger to themselves or others. Lorazepam is used to reduce anxiety, not to sedate to the point where restraints would be necessary.

Choice C reason: Initiating fall precautions is a prudent nursing action after administering lorazepam, especially if given intramuscularly, as the client may experience drowsiness or dizziness, increasing the risk of falls.

Choice D reason: Repeating the dose in 15 minutes is not recommended. The effects of lorazepam should be monitored, and additional doses should be administered based on the client's response and as prescribed by the healthcare provider.

A. "The client generally shares his feelings during group therapy sessions." B. "The client is just like my brother who finally overcame his habit." C. "The client asked me to go on a date with him, but I refused." D. "The client needs to accept responsibility for his substance use."

Correct Answer is B

Explanation

Choice A reason: This statement reflects a neutral observation of the client's behavior in therapy and does not indicate countertransference. Sharing feelings during group therapy sessions is a common and expected part of the therapeutic process, and the staff nurse's comment does not reveal any personal emotional response or projection onto the client.

Choice B reason: This statement is a clear example of countertransference. The staff nurse is identifying the client with a personal family member, which can cloud professional judgment. Such an emotional entanglement may lead to biased care, as the nurse may treat the client based on personal experiences with their brother rather than the client's individual needs and circumstances.

Choice C reason: Declining a client's inappropriate request for a date is a professional boundary that must be maintained. This statement does not reflect countertransference but rather appropriate professional conduct. It is important for the charge nurse to recognize that maintaining boundaries is crucial in a therapeutic setting, especially in cases of substance use disorder where clients may exhibit boundary-testing behaviors.

Choice D reason: This statement could be seen as a professional opinion regarding the client's need for accountability in their recovery process. It does not necessarily indicate countertransference unless the staff nurse's insistence on responsibility is driven by personal feelings or unresolved issues related to substance use.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who just received lorazepam 1 mg IM for anxiety. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as countertransference?

Correct Answer is B

Explanation

A nurse is preparing to administer 7 mg of haloperidol IM to a client who is severely agitated. Haloperidol injection of 5 mg/mL is available. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is providing teaching to a client who is newly diagnosed with Alzheimer's disease. Which of the following treatment options should the nurse include in the teaching?

A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is obtaining a history from a client who has been taking olanzapine to treat schizophrenia. Which of the following questions should the nurse ask the client?

A nurse is caring for a client who has bipolar disorder and is refusing to take prescribed medications. Which of the following ethical principles is the nurse displaying when supporting the client's refusal of medications?

A nurse is planning to lead a support group for clients who have alcohol use disorder. One of the group members is a client who speaks a different language than the nurse. Which of the following individuals should the nurse ask to assist with communication?

A nurse is receiving a change-of-shift report about a group of assigned clients at a mental health facility. Which of the following clients should the nurse assess for risks related to sensory impairments?