A nurse on an inpatient mental health unit is admitting a client.

Exhibits

The nurse is reviewing the client's medical record at 0830 on day 2 of admission.

For each finding, click to specify whether the finding indicates a potential improvement in or a potential worsening of the client's condition.

Blood pressure

Gait when ambulating

Lithium level

Urine amount and color

Blurred vision

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Blood pressure Potential worsening: The blood pressure dropped from 114/64 mm Hg on Day 1 to 98/56 mm Hg on Day 2, indicating a potential worsening as it decreased.

Gait when ambulating - Potential worsening: The client's gait was noted to be uncoordinated when ambulating to the bathroom on Day 2, suggesting a potential worsening in motor coordination or balance.

Lithium level Potential worsening: The lithium level increased from 1.9 mEq/L on Day 2, exceeding the therapeutic range (less than 1.5 mEq/L), indicating a potential worsening due to lithium toxicity.

Urine amount and color - Potential worsening: polyuria is a sign of lithium toxicity.

Blurred vision Potential worsening: The client reports blurred vision and frequently rubs their eyes on Day 2, indicating a potential worsening of visual acuity or ocular health.

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Correct Answer is B

Explanation

A. Discussing the importance of confidentiality is important but should not be the first action.
Addressing immediate emotional needs and coping strategies takes precedence.

B. Identifying prior coping skills helps establish a foundation for managing the current crisis. It allows the nurse to build on existing strengths and provide support tailored to the adolescents'
individual needs.

C. Reviewing community resources is valuable but should come after addressing immediate emotional needs and identifying coping skills.
D. Initiating referrals may be necessary, but it should follow the identification of coping skills and immediate emotional support.

A. "Older adults are usually diagnosed with depressive disorder as they age." B. "Tell me the reasons you think your mother is depressed." C. "Everyone gets depressed from time to time." D. "You shouldn't worry about this, because depressive disorder is easily treated."

Correct Answer is B

Explanation

A. This statement generalizes the situation and may not address the specific concerns of the daughter. It also does not encourage further exploration of the daughter's observations and feelings.
B. This response invites the daughter to share her observations and concerns, fostering communication and understanding between the nurse and the daughter.
C. This response minimizes the daughter's concerns and may invalidate her feelings.

D. This response dismisses the daughter's worries and oversimplifies the nature of depressive disorder.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is leading a crisis intervention group for adolescents who witnessed the suicide of a classmate. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

An older adult client is brought to the mental health clinic by her daughter. The daughter reports that her mother is not eating and seems uninterested in routine activities. The daughter states, "I'm so worried that my mother is depressed." Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is talking with a newly licensed nurse about client rights while admitted to a mental health facility. Which of the following information should the nurse include? (Select all that apply.)

A nurse is caring for an older adult client. Exhibits Complete the following sentence by using the list of options. Upon assessment, the nurse should recognize that the client is at risk for developing dropdownas evidenced by the client's dropdown

A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?

A nurse is caring for a client who states, "Things will never work out." Which of the following responses should the nurse make?

A nurse is caring for a client who is undergoing electroconvulsive therapy. Which of the following tasks should the nurse delegate to an assistive personnel?

A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?

A nurse is reviewing the day 5 vital signs and nurses' notes. Exhibits A nurse is evaluating the client's response to treatment. Select the 4 findings that indicate the client is progressing with their plan of care.

A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?