A nurse asks a client who is suicidal to make a safety contract, but the client declines.

Which of the following actions should the nurse identify as the priority?.

Assign a staff member to stay with the client at all times.

Lock the doors to the unit and secure windows so they cannot be opened.

Remove any objects from the client's environment that could be used for self-harm.

Provide the client with plastic eating utensils for meals.

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Assigning a staff member to stay with the client at all times is the priority action when a client declines to make a safety contract. This is because the immediate safety of the client is the primary concern in such situations.
Choice B rationale:
Locking the doors to the unit and securing windows so they cannot be opened might be considered a safety measure, but it is not the priority. The focus should be on direct supervision to ensure safety.
Choice C rationale:
Removing any objects from the client’s environment that could be used for self-harm is important, but it is not the priority. The immediate safety of the client through constant supervision is the priority.
Choice D rationale:
Providing the client with plastic eating utensils for meals is a safety measure, but it is not the priority. The immediate safety of the client through constant supervision is the priority.

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Correct Answer is C

Explanation

Choice A rationale:

A lithium level of 1.8 mEq/L is above the therapeutic level for initial treatment (0.8 to 1.4 mEq/L)3.

Choice B rationale:

A lithium level of 1.8 mEq/L is above, not below, the therapeutic treatment level.

Choice C rationale:

A lithium level of 1.8 mEq/L is at the toxic level. A blood lithium level greater than 1.5 mEq/L indicates toxicity.

Choice D rationale:

A lithium level of 1.8 mEq/L is not within the maintenance treatment level (0.4 to 1.3 mEq/L)3.

A. Anxiety. B. Gastrointestinal distress. C. Pain. D. Bipolar disorder. E. Fixation on health. F. Depression. G. Localized amnesia.

Correct Answer is ["A","B","C","E","F"]

Explanation

Choice A rationale:
Anxiety is a common symptom of somatic symptom disorder, as patients often experience significant distress about their physical symptoms.
Choice B rationale:
Gastrointestinal distress, such as stomach pain and diarrhea, can be manifestations of somatic symptom disorder. These symptoms can cause significant distress and disrupt daily life.
Choice C rationale:
Pain, especially when it is not linked to a clear physical cause, can be a symptom of somatic symptom disorder. The distress caused by the pain is often out of proportion to its severity.
Choice D rationale:
Bipolar disorder is a separate mental health condition and is not a symptom of somatic symptom disorder.
Choice E rationale:
Fixation on health, particularly an excessive preoccupation with physical symptoms, is a key feature of somatic symptom disorder.
Choice F rationale:
Depression can often co-occur with somatic symptom disorder, as the distress and disruption caused by the physical symptoms can lead to feelings of sadness and hopelessness.
Choice G rationale:
Localized amnesia is not a symptom of somatic symptom disorder. It is more commonly associated with other mental health conditions, such as dissociative disorders.

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A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse reviews the laboratory report for a client who is receiving lithium three times daily PO. The client's current blood lithium level is 1.8 mEq/L. The nurse identifies that this lab value indicates which of the following?.

Correct Answer is C

Explanation

A nurse is caring for a client in an outpatient clinic. Exhibits The nurse should identify which of the following findings as manifestations of somatic symptom disorder? (Select all that apply.).

Correct Answer is ["A","B","C","E","F"]

Explanation

A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care?.

A nurse is reviewing discharge instructions with a client who has bipolar disorder and is taking lithium. Which of the following manifestations should the nurse include as an indication of mild toxicity?

A nurse is teaching a client who has bipolar disorder about lithium. Which of the following statements should the nurse include in the teaching?.

A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?

Your patient is experiencing extrapyramidal symptoms (EPS) from antipsychotic therapy. You understand that the following medications are used to reverse EPS. (Select All that Apply.).

A nurse on an inpatient mental health unit is caring for a client who was admitted for suicidal ideation. Which of the following statements by the client should the nurse identify as a continuation of suicidal ideation?

Which nursing intervention will have the greatest impact on both the management of care and on milieu environment when considering the clients diagnosed with bipolar disorder?

A nurse is assessing a client who has schizophrenia which has been treated with fluphenazine for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?.

A nurse asks a client who is suicidal to make a safety contract, but the client declines.

Which of the following actions should the nurse identify as the priority?.