A client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting self injury by shooting. The client reports going through a divorce one year ago, job loss four months ago, and suffering from a breakup of a current relationship last week. Which is the most likely source of this client's current feelings of depression?

Feelings of frustration.

A sense of loss.

Poor self-esteem.

A lack of intimate relationships.

Answer and Explanation

The Correct Answer is B

Choice A rationale: While frustration may contribute to distress, the client's recent life events, such as a breakup and job loss, suggest a stronger link to a sense of loss.

Choice B rationale: Experiencing a divorce, job loss, and recent breakup are significant life events that contribute to a profound sense of loss, which can lead to feelings of depression.

Choice C rationale: Poor self-esteem can contribute to depression, but the client's recent life events are more directly related to the current feelings of depression.

Choice D rationale: While a lack of intimate relationships can impact mental health, the recent breakup is a more immediate factor contributing to the client's depression.

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Correct Answer is C

Explanation

Choice A rationale: Involving her in group therapy may be premature, as the client has just started to exhibit changes in behavior. Continuous observation is necessary to assess the nature and sustainability of these changes.

Choice B rationale: Praising her for the new behavior is positive, but continuous observation is essential to monitor for any signs of escalating or problematic behavior.

Choice C rationale: Observing her actions continuously is the most appropriate action at this point. The nurse needs to monitor the client closely to assess the nature of the changes, ensuring they are not indicative of increased agitation or potential harm.

Choice D rationale: Offering her a choice of activities may be appropriate once the nurse has a better understanding of the clien's current state. However, continuous observation is the priority.

A. Tell me what you think should happen. B. What do you think you should do? C. How serious was the collision? D. Call for transportation to the hospital.

Correct Answer is D

Explanation

Choice A rationale: Asking the client what they think should happen is vague and does not offer any direction or support.

Choice B rationale: This response encourages is vague and does not offer any direction or support but instead puts the burden of decision-making on the client who is overwhelmed and distressed.

Choice C rationale: Inquiring about the seriousness of the collision is important but may not be the most immediate concern when the client is seeking guidance on what to do.

Choice D rationale: This response shows empathy and concern for the client's well-being and helps the client take action to cope with the crisis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy. Which action should the nurse implement?

Correct Answer is C

Explanation

The occupational health nurse is working with an employee who was just notified that their child was involved in a motor vehicle collision and taken to the hospital. The employee states, "I can't believe this. What should I do?" Which response is best for the nurse to provide in this crisis?

Correct Answer is D

Explanation

The nurse is reviewing an intake mental health assessment with a client who is seeking services for depression. The client reports feeling dizzy, excessively tired, experiencing headaches, and back pain. Which symptom should the nurse suspect is related to the client's feelings of depression?

The nurse is providing care for a client diagnosed with a borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the nurse use when changing this client's dressings?

During admission to the psychiatric unit, a client is extremely anxious and reports being worried about the sun coming up the next day. Which intervention is most important for the nurse to implement during the admission process?

The nurse interacts with a client who is very depressed and slow to respond to questions. The nurse asks the client to describe current feelings, but the client looks down at the table. Which action is best for the nurse to implement?