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 D

Explanation

A. The healthcare provider's history and physical may provide information about the client's overall health but may not specifically address the observed symptoms.
B. Recent urine drug testing (UDT) results may reveal drug use but may not be directly related to the observed involuntary movements.
C. The baseline nursing admission assessment may provide general information but may not specifically address medication side effects.
D. The Abnormal Involuntary Movement Scale (AIMS) is specifically designed to assess and document involuntary movements associated with psychotropic medications, making it the most relevant assessment tool in this situation.

A. Have you experienced recent stresses? B. What foods do you like to eat? C. Do you often feel sad? D. Have you experienced sleep changes?

Correct Answer is C

Explanation

A. Inquiring about recent stresses is relevant but may not specifically address the emotional state associated with depression.
B. Asking about food preferences is important for a comprehensive assessment but may not be the most direct question for assessing depression.
C. Inquiring about whether the client often feels sad is crucial for assessing the emotional aspect of depression.
D. While changes in sleep patterns are significant, the question about feeling sad directly addresses the emotional component of depression, which is important for a comprehensive assessment.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client’s record should the nurse review?

Correct Answer is D

Explanation

A client at the mental health center reports difficulty concentrating at work, feeling very tired during the day, and sleeping 4 to 5 hours at night. To further assess for depression, which question is most important for the nurse to ask?

Correct Answer is C

Explanation

An adolescent who is exhibiting a depressed affect receives a prescription for an antidepressant drug. While the client is taking the antidepressant, which comparison of the client’s behavior before and after taking the drug is most important for the nurse to obtain?

The nurse is caring for a client who is a refugee from another country and who is experiencing daily episodes of anxiety. The client communicates minimally with the nurse, looking away and appearing distressed. Which intervention is most important for the nurse to do first?

An adolescent female with an eating disorder is admitted to the in-patient psychiatric unit. Which intervention should the nurse implement?

The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?

A client with post-traumatic stress disorder (PTSD) is experiencing a dissociative disorder episode. The situation quickly escalates, and the client becomes physically aggressive. Which intervention should the nurse implement first?

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?

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?