A nurse is reviewing the medical records of a group of clients. For which of the following clients should the nurse recommend a referral for assertive community treatment (ACT)?

A client who has a new diagnosis of major depressive disorder

A client who has repeated acute care admissions due to schizophrenia

A client who has requested family therapy following the death of a family member

A client who has physical injuries following an incident of partner violence

Answer and Explanation

The Correct Answer is B

A. A client who has a new diagnosis of major depressive disorder: While major depressive disorder can significantly impact functioning and may require treatment, it typically does not meet the criteria for ACT, which is primarily designed for individuals with severe and persistent mental illness.

B. A client who has repeated acute care admissions due to schizophrenia: Repeated acute care admissions due to schizophrenia suggest significant challenges in managing the illness and maintaining stability in the community. This client may benefit from the intensive support and comprehensive services provided by ACT to prevent future hospitalizations and promote community integration.

C. A client who has requested family therapy following the death of a family member: Family therapy may be an appropriate intervention for supporting this client's grieving process and addressing family dynamics. However, it does not necessarily indicate the need for ACT, which is focused on individuals with severe and persistent mental illness.

D. A client who has physical injuries following an incident of partner violence: While this client may require support and interventions to address the effects of partner violence, it does not specifically indicate the need for ACT unless there are underlying severe and persistent mental health issues contributing to the situation.

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Correct Answer is C

Explanation

A. “Decreased startle response to loud noises.”: Individuals with PTSD often have an exaggerated startle response to loud noises or unexpected stimuli. This heightened startle response is a common symptom of hyperarousal associated with PTSD. Therefore, a decreased startle response would be unexpected in this context.

B. “Reports uninterrupted sleep of 10 to 12 hr each night.”: Sleep disturbances are common among individuals with PTSD. Symptoms can include difficulty falling asleep, staying asleep, or experiencing nightmares related to the traumatic event. Therefore, reports of uninterrupted sleep for 10 to 12 hours each night would be unexpected in someone with PTSD.

C. “Reluctance to discuss the event that precipitated the distress.”: Avoidance of trauma-related thoughts, feelings, or reminders is a hallmark symptom of PTSD. Individuals with PTSD often avoid discussing or thinking about the traumatic event to cope with distressing memories or emotions. Therefore, reluctance to discuss the precipitating event is a common manifestation of PTSD.

D. “Reports feelings of acute distress that began 2 weeks ago.”: PTSD symptoms typically develop shortly after experiencing a traumatic event, but the diagnosis of PTSD requires that symptoms persist for at least one month. Acute distress that began two weeks ago may indicate an acute stress reaction rather than PTSD. PTSD involves persistent symptoms beyond the acute phase of the trauma.

Correct Answer is ["0.4"]

Explanation

To find out how many milliliters (mL) the nurse should administer, we first need to determine the total dose required per administration. The client is receiving haloperidol 2 mg IM every 6 hours.

First, let's calculate the total dose required per administration:

2 mg (total dose) / 1 dose = 2 mg

Next, we need to determine how many milliliters (mL) of the medication solution contain this dose. The concentration of the haloperidol solution is 5 mg/mL.

We can set up a proportion to find the volume of the solution:

2 mg (dose required) / x mL (volume to administer) = 5 mg/mL (concentration)

Cross-multiplying:

2 mg * 1 mL = 5 mg * x mL

2 mL = 5x

To isolate x (the volume to administer), we divide both sides by 5:

x = 2 mL / 5

x = 0.4 mL

So, the nurse should administer 0.4 mL of haloperidol

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A nurse is reviewing the medical records of a group of clients. For which of the following clients should the nurse recommend a referral for assertive community treatment (ACT)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who has posttraumatic stress disorder (PTSD) to a community mental health facility. Which of the following manifestations should the nurse expect when completing the admission assessment?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving haloperidol 2 mg IM every 6 hr. Available is haloperidol 5 mg/mL. How many mu should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.4"]

Explanation

A nurse is planning care for a client who has major depressive disorder and is being admitted following a suicide attempt. Which of the following interventions is the nurse's priority?

A nurse in a well-child clinic receives a phone call from the parent of an adolescent client. The parent states. "I think my son might try to kill himself." Which of the following statements by the parent is the priority for the nurse to investigate further?

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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?

A charge nurse in a community mental health clinic is discussing ethical concepts of client care with a newly licensed nurse. The charge nurse should use which of the following situations as an example of fidelity?

A nurse is assessing a client who has delirium as a result of sepsis. Which of the following manifestations should the nurse expect? (Select all that apply.)

A nurse is caring for a client who has become violent and is threatening self-harm following a crisis. After ensuring enough staff are available. which of the following actions should the nurse take first?

A nurse is caring for a client who has posttraumatic stress disorder (PTSD) after being physically assaulted. The client is unable to recall any details of the event. Which of the following defense mechanisms should the nurse recognize that the client is displaying?