A male client, assessed in the emergency department (ED), has a strong odor of alcohol on his breath. The client denies thoughts of harm to self or others, and the healthcare provider discharges the client. As the client begins to leave, the nurse overhears the client mumble, “Now I’m going to shoot myself.” Which intervention should the nurse implement?

Inquire about the client’s support system.

Ask the client to repeat his comment.

Stop the client from leaving the ED.

Record the statement in the client’s chart.

Answer and Explanation

The Correct Answer is C

A.   Inquiring about the client’s support system may be important, but the immediate concern is the statement indicating a potential risk of harm.
B.   Asking the client to repeat the comment may not be as effective as taking immediate action to prevent harm.
C. Stopping the client from leaving the ED is the priority to ensure the client's safety and prevent the potential act of self-harm.
D.   Recording the statement in the client's chart is important but should be done after taking immediate action to address the potential risk.

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Correct Answer is A

Explanation

A. Feeling angry, embarrassed, and helpless may indicate subconscious blame or judgment toward the client for staying in an abusive relationship. It's important for the nurse to recognize and address these feelings to provide non-judgmental and supportive care.
B. Difficulty accepting the explanation about how the injuries occurred could contribute to these feelings, but it is not the primary cause in this context.
C. Limited experience in caring for clients affected by family violence may contribute to discomfort, but it does not explain the specific emotions described.
D. While a personal history of abuse could impact the nurse's feelings, the question is asking for the immediate cause of the emotions during the current interaction with the client.

A. Alprazolam B. Lithium C. Benztropine D. Magnesium

Correct Answer is C

Explanation

A. Alprazolam is a benzodiazepine used for anxiety and should not necessarily be discontinued solely based on discontinuation of an antipsychotic.
B. Lithium is a mood stabilizer commonly used in bipolar disorder but is not necessarily discontinued with the discontinuation of an antipsychotic.
C. Benztropine is an anticholinergic medication often used to manage extrapyramidal symptoms (EPS) associated with antipsychotic medications. If the antipsychotic is discontinued,
benztropine may also be discontinued.
D. Magnesium is not typically associated with antipsychotic use, and its discontinuation would depend on the specific indication and circumstances.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has been the victim of intimate partner violence. During the interview, the nurse feels angry, embarrassed, and helpless. Which explanation best describes the cause of the nurse’s emotions?

Correct Answer is A

Explanation

The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued?

Correct Answer is C

Explanation

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?

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?

While visiting the community mental health center, a client with a diagnosis of major depressive disorder asks the nurse if what is shared with the staff will be shared with family members. How should the nurse respond to this client?

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?

Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?

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

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?