A spouse brings a client to an extremely busy emergency department due to erratic behavior and expressions of despair.

When the triage registered nurse asks if the client feels suicidal now, the client shrugs their shoulders. Based on these findings, which nursing responsibility is the practical nurse expected to be assigned?

Ask the client to make a verbal contract to not harm self.

Return the client to the waiting room with the spouse.

Document that the client is not currently suicidal.

Place the client in an inside hallway with one-on-one observation.

Answer and Explanation

The Correct Answer is D

Choice A rationale
While making a verbal contract not to harm oneself can be a part of suicide prevention strategies, it is not the immediate responsibility in this scenario. The client’s erratic behavior and expressions of despair indicate a high level of distress and potential risk for self-harm.
Choice B rationale
Returning the client to the waiting room with the spouse does not ensure the client’s safety. The spouse may not be equipped to manage the client’s current emotional state, and the busy environment of the waiting room may exacerbate the client’s distress.
Choice C rationale
Documenting that the client is not currently suicidal is not appropriate in this situation. The client’s non-verbal cues (shrugging their shoulders when asked about suicidal thoughts) may indicate ambivalence or uncertainty about their intent to harm themselves.
Choice D rationale
Placing the client in an inside hallway with one-on-one observation is the most appropriate action. This ensures the client’s safety, allows for continuous monitoring of the client’s condition, and provides an opportunity for further assessment and intervention.

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Correct Answer is A

Explanation

Choice A rationale
The patient likely interpreted the UAP’s behavior as potentially harmful. This is a common reaction in confused older adults, especially when they are awakened unexpectedly. The patient may not have fully understood the situation and reacted out of fear or confusion.
Choice B rationale
While it’s true that older adults can sometimes demonstrate exaggerations of behaviors used earlier in life, there’s no information in the scenario to suggest this is the case.
Choice C rationale
There’s no evidence to suggest that the patient learned violent behavior by watching other patients act out. It’s more likely that the patient reacted out of fear or confusion.
Choice D rationale
While crowding can increase stress and agitation in some individuals, there’s no information in the scenario to suggest that this is a factor in the patient’s behavior.

A. Teach the client techniques for coping with the mother’s anger. B. Ask if the mother could come in for a hearing evaluation. C. Tell the client it appears the mother has a hearing loss. D. Inform the client to ignore the behavior and treat the mother with love.

Correct Answer is B

Explanation

Choice A rationale
While teaching the client techniques for coping with the mother’s anger might be helpful, it does not address the root cause of the problem. The mother’s anger and inappropriate responses could be due to frustration from not being able to hear properly.
Choice B rationale
The mother’s behavior of not responding when her back is turned and becoming increasingly angry could be signs of hearing loss. A hearing evaluation would help determine if this is the case and appropriate interventions can be put in place.
Choice C rationale
Telling the client that it appears the mother has a hearing loss is not the best intervention because it is based on assumption without any professional evaluation. It is important to have a professional evaluation before making such conclusions.
Choice D rationale
Informing the client to ignore the behavior and treat the mother with love does not address the potential issue of hearing loss. Ignoring the problem does not solve it and could lead to further frustration and misunderstanding.

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Naxlex Comprehensive Predictor Exams

A confused older adult patient in a skilled nursing facility was asleep when unlicensed assistive personnel (UAP) entered the room quietly and touched the bed to see if it was wet. The patient awakened and hit the UAP in the face. Which statement best explains the patient’s action?

Correct Answer is A

Explanation

A client reports to the nurse that her elderly mother has become increasingly angry and responds inappropriately to conversations within the past few months. She notes that her mother does not respond when the mother’s back is turned. What is the best intervention for the nurse?

Correct Answer is B

Explanation

Prozac 30mg PO is ordered for a client. Prozac is available in 10mg tablets. How many tablets will you administer?

A nurse is providing a community health education class about suicide prevention. Which of the following should the nurse identify as risk factors for suicide? (Select all that apply).

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A patient returned from a procedure after receiving general anesthesia and is aggressive and confused. The nurse knows that the patient is experiencing: