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 A

Explanation

A. "Has a family member indicated that you should cut down on your drinking?”: This question assesses whether there have been any external concerns or criticisms related to the client's alcohol consumption, which is a common feature in alcohol use disorder.

B. “Have you had a glass of wine in the last week?”: While this question assesses recent alcohol consumption, it does not specifically address problematic drinking patterns or consequences associated with alcohol use disorder.

C. “Do you drink alcohol with your friends?”: This question addresses social drinking behavior but does not specifically focus on the potential for alcohol use disorder or problematic drinking patterns.

D. "Do you enjoy drinking alcohol?”: While enjoyment of alcohol may be relevant to the overall assessment, it does not specifically address problematic drinking patterns or consequences associated with alcohol use disorder.

A. Slow speech B. Rapid mood changes C. Hallucinations D. Unaltered level of consciousness E. Restlessness

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

Explanation

A. Delirium often causes disorganized thinking and communication, but speech can be either slow or rapid and incoherent. Slow speech is not a definitive sign of delirium.

B.Rapid mood changes are commonly seen in delirium. Clients may exhibit sudden shifts in mood, such as becoming agitated, anxious, irritable, or euphoric, often without apparent cause.

C.Hallucinations, both visual and auditory, are common manifestations of delirium. Clients may perceive things that are not present, hear voices, or experience other sensory distortions.

D.Delirium typically involves an altered level of consciousness, which can range from hyperalertness to lethargy. An unaltered level of consciousness is not characteristic of delirium.

E.Restlessness, agitation, and an inability to sit still are frequent manifestations of delirium. Clients may exhibit hyperactivity, fidgeting, pacing, or attempting to remove medical devices or clothing.

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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 caring for a client who reports a history of frequent alcohol consumption. Which of the following questions should the nurse ask when screening for alcohol use disorder?

Correct Answer is A

Explanation

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.)

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

Explanation

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

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A home health nurse is caring for a client who reports feeling tired and being unable to grocery shop. Which of the following responses by the nurse is an example of therapeutic communication?

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 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?

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