A nurse is caring for a client three days after admission to an acute care mental health facility for treatment of major depression. The client leaves her current activity, approaches the nurse, and states, "There's no reason to go on living. I just want to end it all." Which of the following nursing interventions is appropriate?

Ask the client if she has a plan to commit suicide.

Notify the client's family and request a visitor to stay with the client until thoughts of suicide are gone.

Recognize the attempt at manipulation and escort the client back to her activity.

Assist the client to her room and allow her to rest before resuming activity.

Answer and Explanation

The Correct Answer is A

Choice A reason: Directly asking the client about suicidal plans is a critical step in assessing risk and determining the need for immediate intervention.

Choice B reason: While involving the family is important, it does not address the immediate risk the client may pose to herself.

Choice C reason: Recognizing the statement as a manipulation attempt is inappropriate; all expressions of suicidal ideation should be taken seriously.

Choice D reason: Allowing the client to rest does not address the immediate risk of suicide and the need for urgent assessment and intervention.

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

Explanation

Choice A reason: Sweating can be an atypical symptom of a myocardial infarction, especially if it is sudden and occurs without exertion.

Choice B reason: Fatigue, particularly if it is new or unexplained, can be a sign of a myocardial infarction.

Choice C reason: Shortness of breath without chest pain can also be an atypical presentation of a myocardial infarction.

Choice D reason: Dizziness, especially if associated with other symptoms, can indicate a myocardial infarction.

Choice E reason: Nausea is another atypical symptom that can occur with a myocardial infarction.

Choice F reason: Pain between the shoulder blades can be an atypical symptom of a myocardial infarction.

A. Cheddar cheese and sourdough bread B. Corned beef and sauerkraut C. Cottage cheese and oranges D. Beer and red wine

Correct Answer is C

Explanation

Choice A reason: Cheddar cheese is high in tyramine, which can interact with MAOIs and cause hypertensive crises, so it should be avoided.

Choice B reason: Corned beef and sauerkraut are also high in tyramine and should be avoided by clients taking MAOIs.

Choice C reason: Cottage cheese and oranges are generally considered safe for clients taking MAOIs as they are low in tyramine.

Choice D reason: Beer and red wine are high in tyramine and should be avoided by clients taking MAOIs due to the risk of severe hypertension.

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Naxlex Comprehensive Predictor Exams

The licensed practical nurse is assisting with collecting data on a female patient. Which of the following findings should be reported to the registered nurse as possible atypical symptoms of a myocardial infarction in the absence of chest pain? Select all that apply.

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

Explanation

A nurse is caring for a client who has depression and is taking a monoamine oxidase inhibitor (MAOI). The nurse should inform the client that their diet may include which of the following foods?

Correct Answer is C

Explanation

The nurse is reinforcing teaching to the patient about the cause of pain from coronary artery disease. The nurse would evaluate the patient as understanding the education if the patient stated which of the following causes the pain from coronary artery disease?

A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. Which of the following is an appropriate food choice for this client?

A nurse is collecting data from a client who has depression to identify his ability to perform activities of daily living (ADLs) prior to discharge. Which of the following data should the nurse collect? (Select all that apply.)

The nurse is reinforcing teaching for a patient with chronic heart failure. Which of the following weight measurements should the nurse ask the patient to perform to monitor fluid status at home?

The nurse who is assessing a patient with major depression would expect to observe which of the following symptoms?

A nurse is contributing to the plan of care for a client who is newly admitted with severe depression. Which of the following actions should be added to the plan of care?

Marge is a 68-year-old woman with a long history of bipolar disorder. She is brought to the ED by her sister, who reports that Marge has been increasingly agitated, unable to sleep, and told her daughter that the mayor was calling her for advice on running the city. The behavior is an example of:

A nurse is caring for a client who has depression. After two days of treatment, the nurse notices that the client is suddenly more active and there are no longer signs of a depressive state. Which of the following interventions should the nurse recommend for the plan of care?