A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After showing the client to his room, which of the following nursing actions is most therapeutic at this time?

Have the client join a therapy group.

Suggest that the client rest in bed.

Remain with the client for a while.

Medicate the client with a sedative.

Answer and Explanation

The Correct Answer is C

Remaining with the client provides them with a sense of security, reassurance, and support. It shows the client that they are not alone and that the nurse is there to provide assistance and care. By being present and offering a calming presence, the nurse can help the client feel more at ease and gradually reduce their anxiety.

It's important to note that the other options are not the most appropriate actions in this situation:

A- Having the client join a therapy group may be overwhelming and may not be suitable during the acute phase of panic-level anxiety.

B- Suggesting that the client rest in bed may not address their immediate anxiety and may not be feasible if the client is experiencing intense anxiety symptoms.

D- Medicating the client with a sedative should be done based on a healthcare provider's order and assessment of the client's condition. It is not the initial therapeutic intervention and should only be considered if other non-medication interventions are ineffective or if the client's anxiety becomes severe and unmanageable.

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Correct Answer is A

Explanation

In this scenario, the nurse's priority should be initiating suicide precautions. Safety is of utmost importance when caring for a client following a suicide attempt. By implementing suicide precautions, the nurse can take steps to ensure the client's physical and emotional well-being, such as removing potential means of self-harm and closely monitoring the client's behavior. This action aims to prevent further harm and promote a safe environment for the client.

Incorrect:

B- Administering the Hamilton Depression Scale: While assessing the client's level of depression is important, it is not the priority in this situation. The client has just attempted suicide, indicating a high level of risk. Therefore, the nurse should prioritize safety measures and immediate interventions rather than administering a depression scale.

C- Making a contract with the client for eating behavior: While addressing the client's eating behavior is important, it is not the priority in this situation. The client has just attempted suicide, indicating a significant risk to their life. Ensuring their safety and providing appropriate mental health support take precedence over addressing their eating behavior.

D- Reviewing the client's toxicology laboratory report: While reviewing the client's toxicology report may provide valuable information about substance abuse, it is not the priority in this scenario. The immediate concern is the client's safety following a suicide attempt. The nurse should focus on implementing suicide precautions and addressing the client's emotional and physical well-being.

A. "Has alcohol use affected your performance at work?" B. "Do you receive treatment for any mental health disorders?" C. "At what age did you begin drinking alcohol?" D. "Have you received prior treatment for substance use disorder?"

Correct Answer is A

Explanation

This question directly addresses the impact of alcohol use on the client's work-related behaviors and performance, which is an essential aspect of their psychosocial functioning. It can provide valuable information about potential impairments in work productivity, relationships with colleagues, and overall job stability.

While the other questions are also relevant and important in assessing a client with a history of alcohol use disorder, they focus on different aspects of the client's history and treatment. For example:

B- "Do you receive treatment for any mental health disorders?" helps to assess if there are coexisting mental health issues that may be contributing to or affected by alcohol use.

C- "At what age did you begin drinking alcohol?" helps to understand the timeline of the client's alcohol use and potential early risk factors for developing alcohol use disorder.

D- "Have you received prior treatment for substance use disorder?" provides insights into the client's past attempts at addressing their alcohol use and any prior experiences with treatment.

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A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After showing the client to his room, which of the following nursing actions is most therapeutic at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions is the nurse's priority?

Correct Answer is A

Explanation

A nurse is assessing a client who has a history of alcohol use disorder. Which of the following questions should the nurse include to deter the use of alcohol affects the client's psychosocial behaviors?

Correct Answer is A

Explanation

A nurse is planning care for a client who has depression. The nurse notes that the client has weight loss, an inability to concentrate, an inability to complete everyday tasks, and a preference to sleep all day. Which of the following interventions should be included in the plan of care?

A nurse notices that a client who has moderate anxiety is pacing the hall and mumbling As the nurse approaches the client, he states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?

A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following findings should the nurse expect?

A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity?

A charge nurse is discussing suicide interventions with nursing staff. Which of the following should the nurse identify as an example of secondary intervention?

A nurse is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse include in the discussion as a health risk of heroin use?

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

A nurse is caring for an adolescent female who has an eating disorder. The client is 162.6 cm (64 in) tall and weighs 38.56 kg (85 lb). Upon assessment, which of the following manifestations should the nurse expect? (Select all that apply.)