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 working in a pediatric emergency department can be stressful, the information provided does not suggest an increased risk for suicide in this scenario.
B. Adolescents experiencing major life changes, such as parental divorce, are at an elevated risk for suicide.
C. While the loss of a significant other can contribute to increased suicide risk in older adults, the information provided does not indicate an immediate concern.
D. While being a single working mother with young children is challenging, the information provided does not suggest an increased risk for suicide in this scenario.

A. Explain to the client that her behavior invades the rights of the nursing staff. B. Teach the client strategies to control her obsessive-compulsive behavior. C. Ask the client to explain why she is keeping a detailed record of her nursing care. D. Encourage the client to express her feelings regarding the upcoming procedure. E. None F. None

Correct Answer is D

Explanation

A. Explain to the client that her behavior invades the rights of the nursing staff: This approach is confrontational and dismisses the client’s coping mechanism. It does not promote a therapeutic nurse-client relationship.

B. Teach the client strategies to control her obsessive-compulsive behavior: This is not the appropriate time for teaching behavioral strategies, especially when the client is experiencing stress related to an upcoming invasive procedure.

C. Ask the client to explain why she is keeping a detailed record of her nursing care: While this might offer insight, it can come across as intrusive or judgmental. It also shifts the focus away from emotional support.

D. Encourage the client to express her feelings regarding the upcoming procedure: Clients with obsessive-compulsive personality disorder often rely on control and orderliness to manage anxiety. The nurse should recognize that the client’s behavior may be a coping mechanism for procedure-related stress. Encouraging expression of feelings promotes trust and addresses the underlying anxiety.

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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

Which individual should the nurse consider at the highest risk for suicide?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

A male client with schizophrenia continues to talk to others on the mental health unit using tangential speech. What intervention should the nurse implement?

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