A client diagnosed with major depressive disorder tells the nurse that he and his family would be better off if he were gone. Which of the following is the nurse's priority response?

"Do you really think your family would be better off without you?"

"Tell me what is happening right now."

"When did you first start feeling this way?"

"Are you thinking of harming yourself?"

Answer and Explanation

The Correct Answer is D

Choice A reason:
Asking the client if they really think their family would be better off without them could potentially validate the client's feelings of worthlessness and is not a priority when immediate safety concerns are present.

Choice B reason:
While it's important to understand the client's current situation, this open-ended question may not directly address the risk of harm the client might pose to themselves. It should follow after ensuring the client's safety.

Choice C reason:
Inquiring about the onset of these feelings is part of a thorough assessment but is not the most immediate concern when a client expresses thoughts that may indicate a risk of self-harm.

Choice D reason:
This direct question addresses the immediate safety concern and is the priority response when a client indicates they may be a danger to themselves. It is essential to assess for suicidal ideation directly to take appropriate steps to ensure the client's safety.

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Correct Answer is ["B","D"]

Explanation

Choice A reason:
This statement is incorrect. Nausea, vomiting, and diarrhea can be side effects of lithium and are concerns while on this medication. It is important for clients to report these symptoms to their healthcare provider, as they can be signs of lithium toxicity.

Choice B reason:
This statement is correct. Maintaining adequate sodium intake is important while taking lithium. Sodium levels can affect lithium levels in the body, and sudden changes in sodium intake can lead to lithium toxicity or decreased effectiveness of the medication.

Choice C reason:
This statement is incorrect. Lithium does not necessarily need to be taken on an empty stomach. It can be taken with or without food, although taking it with food may help reduce stomach upset.

Choice D reason:
This statement is correct. Regular monitoring of blood levels is essential during the first month of lithium therapy to ensure that lithium levels are within the therapeutic range and to avoid toxicity. The frequency of monitoring may change based on the results and as treatment continues.

A. Escort the client to the common area. B. Contact security for possible restraints. C. Stay with the client. D. Stay away from the client.

Correct Answer is C

Explanation

Choice A reason:
Escorting the client to the common area is not the priority action. While being around others can sometimes be comforting, during a panic attack, the client may feel overwhelmed and exposed, which could exacerbate the situation.

Choice B reason:
Contacting security for possible restraints should be a last resort and is not the priority action. Restraints can increase anxiety and fear, potentially escalating the panic attack. The use of restraints is only considered when the client is at risk of harming themselves or others and all other interventions have failed.

Choice C reason:
Staying with the client is the priority action. During a panic attack, the client needs reassurance and a sense of safety. The nurse's presence can provide comfort. The nurse should remain calm, use a quiet voice, and avoid making any sudden movements. Implementing relaxation techniques and promoting a calming environment are also beneficial.

Choice D reason:
Staying away from the client is not the priority action. Leaving the client alone can increase feelings of isolation and fear. The nurse should provide continuous observation and support during the panic attack.

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A client diagnosed with major depressive disorder tells the nurse that he and his family would be better off if he were gone. Which of the following is the nurse's priority response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to teach a client about the lithium prescription for treating bipolar disorder. Which of the following statements should the nurse include in the teaching?

Correct Answer is ["B","D"]

Explanation

A nurse is caring for a client with generalized anxiety disorder who is experiencing a panic attack. Which of the following is the nurse's priority action for this client?

Correct Answer is C

Explanation

A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority?

A nurse is caring for a client who is prescribed extended-release Morphine. The nurse should recognize which of the following assessment cues as an indication of opioid overdose?

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A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?

A nurse who works in a psychiatric unit is caring for a client diagnosed with bipolar disorder. The client comes to the nurse's station at 0300, demanding that the nurse call the provider immediately. Which of the following responses should be an appropriate response by the nurse?

A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?

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