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 B

Explanation

A. Give the client a cup of hot black tea before bed: Consuming caffeinated beverages such as black tea before bed can interfere with sleep and exacerbate sleep disturbances. This instruction is not appropriate for addressing sleep issues in Alzheimer's disease.

B. Wake the client at the same time each morning: Maintaining a consistent wake-up time can help regulate the client's sleep-wake cycle and promote better sleep hygiene. Consistency in waking time is an important aspect of managing sleep disturbances in Alzheimer's disease.

C. Take the client for a walk 2 hours before bedtime each night: Engaging in physical activity during the day, including taking a walk, can promote better sleep patterns. However, engaging in vigorous physical activity close to bedtime may have the opposite effect and disrupt sleep.

D. Allow the client to take a 90-min nap immediately after lunch: While brief daytime naps may be beneficial for some individuals with Alzheimer's disease, allowing a 90-minute nap immediately after lunch may interfere with the client's ability to consolidate nighttime sleep and worsen sleep disturbances.

A. “I check my breasts for lumps every day, but I’m still really scared about getting breast cancer.” B. “I have had several negative pregnancy tests but know they are all wrong.” C. “I double-check my pills because think the pharmacist may be putting poison in them.” D. “I feel really nervous when my partner goes to work and i am home alone during the day.”

Correct Answer is A

Explanation

A. “I check my breasts for lumps every day, but I’m still really scared about getting breast cancer.”: This statement reflects excessive worry about a specific medical condition (breast cancer) despite engaging in frequent checking behaviors. It is consistent with illness anxiety disorder.

B. “I have had several negative pregnancy tests but know they are all wrong.”: This statement suggests a belief that contradicts objective evidence (negative pregnancy tests) and may indicate a somatic symptom disorder or a delusional disorder rather than illness anxiety disorder.

C. “I double-check my pills because I think the pharmacist may be putting poison in them.”: This statement reflects mistrust or paranoia about medications and the intentions of the pharmacist. While it involves health-related concerns, it may be more indicative of paranoid ideation or delusional beliefs.

D. “I feel really nervous when my partner goes to work, and I am home alone during the day.”: This statement describes anxiety related to separation from a partner and being alone, which is not a characteristic feature of illness anxiety disorder. It may be more indicative of generalized anxiety disorder or separation anxiety disorder.

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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 providing teaching to the caretakers of a client who has Alzheimer's disease with mild cognitive decline. The client is beginning to experience sleep disturbances. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse on a mental health unit is leading a group therapy session for a group of clients. Which of the following statements should the nurse expect from a client who has illness anxiety disorder?

Correct Answer is A

Explanation

A nurse in an acute care facility is assessing a client who has schizophrenia. The client states. "Walk tall broom short dag bell." The nurse should document the client's speech as which of the following speech patterns?

A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse include?

A nurse is caring for a client who has bipolar disorder. The client says to the nurse. "Give me your pen to cut the pain out of my chest. The nurse should identify that the client is at risk for which of the following?

A nurse is caring for a client who is experiencing visual hallucinations followed by impaired consciousness as a result of alcohol withdraw which of the following conditions should the nurse identify as causing these manifestations?

A nurse is caring for a client who is aggressive toward other clients and has been placed in wrist restraints. After obtaining a prescription for restraints from the provider, which of the following actions should the nurse take?

A nurse is reviewing the medical records of a group of clients. For which of the following clients should the nurse implement seizure precautions?

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 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?