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 C

Explanation

A. While allowing freedom in choosing seats may be acceptable, in this scenario, encouraging a more cohesive and interactive group setting is beneficial.
B. Suggesting that they all sit together to increase interaction is a reasonable approach to enhance group dynamics.
C. Asking the adolescent sitting on the couch to join the group at the table promotes inclusivity and equal participation.
D. Determining which adolescents would like to participate may not be necessary; encouraging all to participate fosters a collaborative atmosphere.

A. Reinforce statements regarding a will to live and realistic plans for the future. B. Discuss the client’s suicide plan. C. Limit time allowed to play video games. D. Encourage the client to discuss thoughts and feelings about wanting to die. E. Restrict visitors to family members only.

Correct Answer is ["A","B","D"]

Explanation

Rationale for A: Reinforcing a will to live and encouraging realistic future plans can promote hope and motivation in a depressed adolescent.

Rationale for B: Discussing the client’s suicide plan is essential for assessing risk and ensuring safety. It allows for intervention if the risk is significant.

Rationale for C: While managing screen time can be beneficial, it is less critical than addressing the underlying emotional issues and ensuring safety.

Rationale for D: Encouraging the client to express thoughts and feelings about wanting to die can provide a safe space for the adolescent to discuss suicidal ideation and help the nurse assess risk more effectively.

Rationale for E: Restricting visitors may not be helpful; maintaining social connections can provide support and reduce feelings of isolation.

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Naxlex Comprehensive Predictor Exams

The nurse is teaching a group of adolescents about assertive communication. Two of the adolescents are seated at a round table and another is sitting on a small sofa nearby. To facilitate group interaction, which intervention is best for the nurse to implement?

Correct Answer is C

Explanation

Which interventions should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)

Correct Answer is ["A","B","D"]

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?

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

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?

A client diagnosed with schizophrenia has been receiving haloperidol for the past year, and the treatment plan includes moving the client to a lower maintenance dosage. Which intervention should the nurse include in this client’s plan of care? (Select all that apply)

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?