A client comes to the emergency department with the chief symptom of "I'm hearing voices telling
me that someone is stalking me. They want to kill me because I have developed a cure for cancer.".
The client tells the nurse that he carries a knife and will stab anyone he thinks is a threat to him.
Which aspects of mental health should be of greatest immediate concern to the nurse? (More than
one answer may be correct.)
A. Happiness
B. Appraisal of reality
C. Control over behavior
D. Effectiveness in work
E. Healthy self-concept
ANS: B, C, E
Rationale: The aspects of mental health of greatest concern are the client's appraisal of and his
control over behavior. His appraisal of reality is inaccurate. He has auditory hallucinations,
delusions of persecution, and delusions of grandeur. In addition, the client's control over behavior is
tenuous, as evidenced by his plan to stab anyone who seems threatening. A healthy self-concept is
lacking, as evidenced by the delusion of grandeur. Data are not present to suggest that the other
aspects of mental health (happiness [option A] and effectiveness in work [option D]) are of
immediate concern.
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The nurse is preparing the dosage for a client as per the medication administration record. Which of the following precautions should the nurse always take when preparing medications?
A) Ask another nurse to assist in preparing the medication. B) Avoid relabeling containers with missing labels. C) Check the label of the drug container once before administration. D) Transfer medications from large containers to small containers.
Which of the following colors and sounds would have a healing effect on a client suffering from sinus congestion?
a. The color red and the sound "ha" b. The color yellow and the sound "ya" c. The color green and the sound "hum" d. The color blue and the sound "ah"
The client is to receive HydroDiuril (hydrochlorothiazide) 12.5 mg po daily. Each scored tablet contains 25 mg. How many tablets would the client receive?
A) 1/4 B) 1/2 C) 1 D) 2
A Parkinson's patient is depressed because his drug protocol of L-dopa and Sinemet are no longer controlling his symptoms. The nurse's response that would be the most helpful in-formation is that:
1. other drugs can be combined with L-dopa to increase its effectiveness. 2. the effect of these drugs has an uneven course; symptoms will begin to subside again soon. 3. the two drugs can be given in higher doses to control the symptoms. 4. surgical interventions have been very effective in the control of parkinsonian symptoms.