A homeless female client who reports feeling sad and depressed tells the mental health nurse that in the past two days, the client has only had four hours of sleep. Which action is most important for the nurse to implement within the first 24 hours after treatment is initiated?

Allow the client to rest and sleep.

Begin planning for the client’s discharge.

Encourage verbalization of feelings.

Ensure the client attends groups addressing coping skills for dealing with depression.

Answer and Explanation

The Correct Answer is A

A.   Allowing the client to rest and sleep is a priority, as sleep deprivation can exacerbate symptoms of depression. Addressing immediate physical needs is crucial.
B.   Planning for discharge can be addressed later in the treatment process; the immediate focus should be on ensuring the client's basic needs are met.
C. Encouraging verbalization of feelings is important but should not take precedence over addressing the client's sleep deprivation.
D.   Ensuring the client attends groups addressing coping skills for dealing with depression is valuable but may be addressed after the client has had sufficient rest. Prioritizing sleep helps address the most immediate concern.

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Correct Answer is B

Explanation

A. While marijuana may not be considered highly addictive compared to some substances, the response should address the potential risks and consequences of marijuana use rather than focusing solely on addiction.
B. This response highlights the immediate concern of altering one's ability to think clearly, emphasizing potential risks to both the individual and others.
C. Healthcare providers prescribing marijuana for specific medical purposes does not directly address the student's concern about recreational use.
D. Discussing moral implications may be a subjective approach and may not provide concrete information about the potential risks associated with marijuana use.

A. Advise the mother to call the police if violent behavior occurs again. B. Refer the mother for psychiatric evaluation for anxiety and depression. C. Reinforce the need for the adolescent to attend group therapy sessions. D. Tell the mother to describe her feelings of helplessness to her son.

Correct Answer is A

Explanation

A. Advising the mother to call the police if violent behavior occurs again addresses the safety of the client and others and is a necessary step to ensure appropriate intervention.
B. Referring the mother for psychiatric evaluation is important but may not directly address the immediate safety concern related to the recent violent behavior.
C. Reinforcing the need for the adolescent to attend group therapy sessions is relevant, but the immediate focus should be on addressing the safety issue.
D. Telling the mother to describe her feelings may be helpful for therapeutic communication but may not be the most urgent intervention in response to the reported violent behavior.

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A homeless female client who reports feeling sad and depressed tells the mental health nurse that in the past two days, the client has only had four hours of sleep. Which action is most important for the nurse to implement within the first 24 hours after treatment is initiated?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a high school substance abuse class, a student tells the group, “I know that marijuana is not addicting, so why shouldn’t I use it? Which response is best for the nurse to provide?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

A client with generalized anxiety disorder (GAD) receives a new prescription for lorazepam. Which statement provided by the client requires additional instruction by the nurse?

The nurse is leading a group on the inpatient psychiatric unit. Which approach should the nurse use during the working phase of group development?

The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the client’s history should the nurse further explore?

A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the nurse implement first?

The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?

The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?

A client who is experiencing a severe level of anxiety reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?