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 B

Explanation

A. Disrupting group activities may be a concerning behavior, but it may not necessarily warrant constant observation.
B. Wandering into client’s rooms poses a safety risk to both the client and others, indicating a need for constant observation to prevent potential harm.
C. Talking with nonsensical words is indicative of disorganized thought processes but may not directly necessitate constant observation for safety.
D. Refusing antipsychotic medications is a concerning behavior, but it alone may not be an immediate safety risk that requires constant observation.

A. Allow the client to rest and sleep. B. Begin planning for the client’s discharge. C. Encourage verbalization of feelings. D. Ensure the client attends groups addressing coping skills for dealing with depression.

Correct Answer is A

Explanation

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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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

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?

Correct Answer is A

Explanation

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

While assessing a client with the diagnosis of schizophrenia who wears dentures, the nurse observes that the client’s tongue is “worming”. The client also demonstrates an inability to articulate words clearly. Which additional assessment is most important for the nurse to obtain?

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?

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 charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?

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?

A client with chronic alcohol dependency is admitted due to a recent relapse. Which findings should the nurse expect this client to exhibit? (Select all that apply)