A nurse is conducting an admission interview with a new client who tells the nurse, "My life is so stressful.
I can't take it anymore.”. Which of the following responses should the nurse make first?

"Tell me what makes you feel stressed.”.

"How have you dealt with stress in the past?".

"Let's talk more about what you are experiencing.”.

"Are you thinking of harming yourself?". .

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Asking the client to describe what makes them feel stressed is important for understanding their situation, but it is not the immediate priority when there is concern about self-harm.

Choice B rationale:

Inquiring about the client's past coping mechanisms is relevant, but it should not be the first question when there is a potential risk of self-harm.

Choice C rationale:

Discussing what the client is experiencing is important, but it is not the primary concern when there is a risk of self-harm.

Choice D rationale:

Asking the client if they are thinking of harming themselves is the immediate priority in this situation. It helps assess the client's safety and the need for further intervention. Please let me know if you have more questions or need further explanations. .

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Correct Answer is C

Explanation

Choice A rationale:

Aspartate aminotransferase (AST) is not directly related to lithium toxicity. Elevated AST levels are indicative of liver dysfunction or damage, not lithium toxicity.

Choice B rationale:

White blood cell (WBC) count within the normal range (6,000/mm3) is not a specific indicator of lithium toxicity. It is essential to focus on electrolyte and renal function parameters when assessing lithium toxicity.

Choice C rationale:

Low serum sodium levels (132 mEq/L) can place the client at risk for lithium toxicity. Hyponatremia, often caused by lithium-induced nephrogenic diabetes insipidus, can lead to impaired lithium excretion and increased risk of toxicity.

Choice D rationale:

A calcium level of 10.0 mg/dL is within the normal range and is not directly associated with lithium toxicity. Lithium toxicity primarily affects sodium levels, as mentioned earlier.

A. Identify and schedule alternative group activities for the client. B. Discourage the client from expressing feelings of anger. C. Keep a bright light on in the client's room at night. D. Encourage physical activity for the client during the day.

Correct Answer is A

Explanation

Choice A rationale:

"Identify and schedule alternative group activities for the client.”. This is the most appropriate response as it focuses on engaging the client in alternative group activities. Social isolation is a common issue in individuals with major depressive disorder, and offering alternative group activities can help the client to socialize and find enjoyment in different ways, potentially improving their mood.

Choice B rationale:

"Discourage the client from expressing feelings of anger.”. This choice is not suitable because it discourages the client from expressing feelings of anger. While it's essential to guide the client in managing their anger appropriately, discouraging the expression of emotions can be counterproductive and may lead to emotional suppression, which is not recommended.

Choice C rationale:

"Keep a bright light on in the client's room at night.”. This option is not directly related to managing major depressive disorder. While light therapy can be beneficial for certain conditions like seasonal affective disorder, it may not be the most appropriate intervention for every client with major depressive disorder.

Choice D rationale:

"Encourage physical activity for the client during the day.”. This is a valid intervention for managing major depressive disorder. Regular physical activity has been shown to have a positive impact on mood and can be an effective part of a treatment plan for individuals with depression. However, choice A is more specific to addressing social isolation, which is a common concern in major depressive disorder.

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A nurse is conducting an admission interview with a new client who tells the nurse, "My life is so stressful.I can't take it anymore.”. Which of the following responses should the nurse make first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health facility is reviewing the laboratory results of a client who is taking lithium carbonate.Which of the following findings places the client at risk for lithium toxicity?

Correct Answer is C

Explanation

A nurse is creating a plan of care for a client who has major depressive disorder.Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

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A nurse is conducting an admission interview with a new client who tells the nurse, "My life is so stressful.
I can't take it anymore.”. Which of the following responses should the nurse make first?