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 C

Explanation

A. While sleep deprivation is a concern, the client's impulsive behavior poses a greater immediate risk, making "Risk for self-directed violence related to impulsive behavior" the priority.
B. Ineffective coping may be a contributing factor, but the risk of self-directed violence takes precedence as the primary concern.
C. The client's impulsive behavior increases the risk of self-directed violence, making it the most urgent nursing priority.
D. Imbalanced nutrition is a concern, but the immediate risk of self-directed violence requires more immediate attention.

A. Use relaxation techniques to reduce excessive anxiety. B. Avoid alcohol and other sedatives while taking the medication. C. Move slowly from a sitting position to a standing position. D. Stop taking the medication if the intended effect is not immediate.

Correct Answer is D

Explanation

A. Using relaxation techniques is a positive and appropriate strategy for managing anxiety.
B. Avoiding alcohol and other sedatives is essential as they can potentiate the sedative effects of lorazepam.
C. Moving slowly from a sitting to a standing position is important to minimize orthostatic hypotension, a potential side effect of lorazepam.
D. Stopping the medication if the intended effect is not immediate is not appropriate guidance.
Lorazepam, like many benzodiazepines, may take some time to achieve its full therapeutic effect. Abrupt discontinuation can lead to withdrawal symptoms and should be done under the guidance of a healthcare provider.

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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

Correct Answer is C

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?

Correct Answer is D

Explanation

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?

After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping both feet while pacing the hallway. Which action should the nurse take?

The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?

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

An adolescent who is a heroin addict is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?

A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client’s rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?

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