A mental health nurse is providing preventive care for a group of clients in the community. Which of the following actions by the nurse demonstrates a secondary prevention strategy?

Leading a group discussion with several clients who have schizophrenia and are dealing with tardive dyskinesia.

Screening college students who demonstrate manifestations of depressive disorder.

Training volunteers in an adult day care facility to communicate effectively with clients who have cognitive impairments.

Teaching personal coping skills to a group of adults whose parents have Alzheimer's disease.

Answer and Explanation

The Correct Answer is B

A reason: Leading a group discussion with several clients who have schizophrenia and are dealing with tardive dyskinesia. This action represents tertiary prevention, as it involves managing long-term symptoms and complications of an existing condition (tardive dyskinesia) in clients with schizophrenia.

B reason: Screening college students who demonstrate manifestations of depressive disorder. Screening for depressive disorders is a form of secondary prevention. It aims to identify and treat mental health conditions early before they become more severe, thus preventing further complications.

C reason: Training volunteers in an adult day care facility to communicate effectively with clients who have cognitive impairments. This action is an example of tertiary prevention, focusing on improving care and support for clients with existing cognitive impairments, rather than preventing the onset or progression of the condition.

D reason: Teaching personal coping skills to a group of adults whose parents have Alzheimer's disease. This action represents tertiary prevention, as it aims to help individuals cope with the stress and challenges of caregiving for relatives with Alzheimer's disease, rather than preventing the condition itself.

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Correct Answer is C

Explanation

A reason: Document the client's behavior once every hour. While documenting the client's behavior is important, it should be done more frequently than once every hour. Monitoring should be continuous to ensure the client's safety.

B reason: Keep the client in restraints until the prescription expires. Restraints should be used for the shortest duration necessary to ensure safety, not just until the prescription expires. Regular assessments are needed to determine if they can be removed earlier.

C reason: Conduct a debriefing regarding the client with the unit staff. Debriefing with the unit staff helps ensure everyone is informed about the client's condition, the reasons for using restraints, and the plan for ongoing care. This promotes a team approach to managing the client's behavior.

D reason: Request an evaluation of the client within 12 hours of application of restraints. An evaluation should be conducted much sooner than 12 hours, typically within an hour of applying restraints, to assess the client's physical and mental status and determine if continued use is justified.

A. Urinary retention. B. Blurred vision. C. Headache. D. Bradypnea.

Correct Answer is D

Explanation

A reason: Urinary retention. Urinary retention can occur with these medications, particularly with opioids like hydromorphone, but it is not typically an immediate priority compared to respiratory depression.

B reason: Blurred vision. Blurred vision can be a side effect of medications, but it is not as immediately critical as respiratory function.

C reason: Headache. A headache, while uncomfortable, is not as urgent as respiratory issues when managing clients on these medications.

D reason: Bradypnea. Bradypnea, or slowed breathing, is a serious and potentially life-threatening side effect of both diazepam and hydromorphone. It indicates respiratory depression, which requires immediate intervention to ensure the client's safety.

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A mental health nurse is providing preventive care for a group of clients in the community. Which of the following actions by the nurse demonstrates a secondary prevention strategy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is aggressive toward other clients and has been placed in wrist restraints. After obtaining a prescription for restraints from the provider, which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assessing a client who takes diazepam for anxiety and hydromorphone for severe pain. Which of the following is the priority finding that the nurse should report to the provider?

Correct Answer is D

Explanation

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A nurse is preparing to teach a client who has major depressive disorder and is scheduled to undergo electroconvulsive therapy (ECT). Which of the following statements should the nurse include in the teaching?

A nurse on a mental health unit is planning a group therapy session about assertiveness training. For which of the following clients should the nurse recommend the training?

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