A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment, the client tells the nurse that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the nurse to provide?

Unless your sister has a medical education, ignore her comments.

I can hear that your sister's comments are overwhelming you.

Do you think it is possible that you might be a hypochondriac?

Besides your sister's comments, what in your life is troubling you?

Answer and Explanation

The Correct Answer is D

Choice A rationale: Ignoring comments about the sister's lack of medical education may not address the client's feelings and concerns. It is essential to explore the client's emotions.

Choice B rationale: Acknowledging that the sister's comments are overwhelming is supportive but may not actively address the client's self-perception.

Choice C rationale: Asking if the client thinks she might be a hypochondriac could be interpreted as judgmental and may not promote an open discussion about the client's concerns.

Choice D rationale: Asking about what is troubling the client, besides her sister's comments, encourages the client to express her feelings and provides an opportunity for the nurse to understand the client's perspective and concerns.

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Correct Answer is B

Explanation

Choice A rationale: Telling the client they are out of control may escalate the situation and provoke further aggression. It is not a therapeutic or de-escalation technique.

Choice B rationale: Staying quietly with the client is a calm and non-confrontational approach. It allows the client to express emotions while conveying a supportive presence.

Choice C rationale: Distracting the client by offering finger foods may not be appropriate during a shouting episode, as it may be perceived as dismissive of the client's feelings or concerns.

Choice D rationale: Ignoring the client's acting-out behavior is not the best option. The nurse should acknowledge the client's emotions and provide support rather than ignoring the distress.

A. Administer an antianxiolytic medication. B. Insert fecal management tube. C. Insert peripheral intravenous catheter. D. Crush pills and place in applesauce.

Correct Answer is C

Explanation

Choice A rationale: Administering an antianxiolytic medication may be appropriate, but addressing the client's fluid and electrolyte imbalance is the priority.

Choice B rationale: Inserting a fecal management tube is not the first action to take in response to hemoccult positive liquid stools; addressing fluid balance is more urgent.

Choice C rationale: Inserting a peripheral intravenous catheter is the priority to address the client's fluid and electrolyte imbalance and provide necessary hydration and medications.

Choice D rationale: Crushing pills and placing them in applesauce may be considered, but the client's fluid and electrolyte imbalance needs prompt attention first.

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Naxlex Comprehensive Predictor Exams

A client admitted to the mental health unit starts to shout and scream at the nurse. Which approach is best for the nurse to take?

Correct Answer is B

Explanation

Two days after being admitted with alcohol withdrawal, a client has constant liquid stools and abdominal cramping. The emesis and stool are hemoccult positive. The client is confused and refusing to take oral medication. Which action should the nurse implement first?

Correct Answer is C

Explanation

The nurse is providing care for a client diagnosed with a borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the nurse use when changing this client's dressings?

A client with chronic alcohol dependence is diagnosed with Wernicke-Korsakoff syndrome. The client is experiencing memory loss and confusion. Which medication should the nurse administer to help alleviate the client's symptoms?

A college student is admitted to the mental health unit following a drug overdose. The student tells the nurse about the overdose following the end of a romantic relationship. Which is the primary goal for hospitalization that should be included in this client's plan of care?

The healthcare provider prescribes lithium carbonate for a client diagnosed with bipolar, manic depression. It is most important for the nurse to review which laboratory finding prior to beginning the drug therapy?

During admission to the psychiatric unit, a client is extremely anxious and reports being worried about the sun coming up the next day. Which intervention is most important for the nurse to implement during the admission process?

The nurse is preparing a client for discharge who has been taking alprazolam long-term for generalized anxiety disorder (GAD). When evaluating the client's grasp of the discharge teaching, which statement made by the client shows an understanding of the most important self-care goal?

A client who is experiencing a severe level of anxiety and reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?

After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy. Which action should the nurse implement?