An adolescent client is admitted to the postoperative unit following open reduction of a fractured femur which occurred when the client fell down the stairs at a party. The nurse notices needle marks on the client's arms. Which assessment findings should the nurse document related to suspected narcotic withdrawal?

Vomiting, seizures, and loss of consciousness.

Hypotension, shallow respirations, and dilated pupils.

Agitation, sweating, and abdominal cramps.

Depression, fatigue, and dizziness.

Answer and Explanation

The Correct Answer is C

Choice A reason: Vomiting may occur in narcotic withdrawal, but seizures and loss of consciousness are more characteristic of severe withdrawal from other substances like alcohol or benzodiazepines. Narcotic withdrawal typically presents with agitation, sweating, and gastrointestinal symptoms, not primarily neurological collapse, making this less accurate for documenting suspected opioid withdrawal in this adolescent.

Choice B reason: Hypotension and shallow respirations are not typical of narcotic withdrawal; they suggest overdose or other conditions. Dilated pupils occur in withdrawal, but agitation and sweating are more prominent. This combination does not fully capture the autonomic and gastrointestinal symptoms of opioid withdrawal, making it incorrect for documentation.

Choice C reason: Agitation, sweating, and abdominal cramps are hallmark signs of narcotic withdrawal, reflecting autonomic hyperactivity and gastrointestinal distress due to opioid cessation. These symptoms align with the clinical presentation of opioid withdrawal in an adolescent with needle marks, supported by addiction medicine evidence, making this the best choice for documentation.

Choice D reason: Depression, fatigue, and dizziness may occur in later withdrawal phases but are less specific than agitation, sweating, and cramps, which are acute and prominent in early narcotic withdrawal. These symptoms are too vague to capture the immediate autonomic response, making this incorrect for documenting suspected opioid withdrawal.

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Correct Answer is C

Explanation

Choice A reason: Asking about other children shifts focus from the mother’s expressed depression and does not address her emotional distress or safety. Assessing for suicidal or harmful thoughts is critical given her depression, making this less urgent and incorrect for responding to her immediate emotional state.

Choice B reason: Journaling may help process emotions but does not address the immediate risk of depression-related self-harm or harm to the child. Assessing for suicidal ideation is the priority to ensure safety, making journaling secondary and incorrect for the nurse’s initial response to this mother.

Choice C reason: Asking about thoughts of harming herself or her child is critical, as the mother’s depression raises safety concerns. This assesses suicide or infanticide risk, prioritizing safety in a high-stress caregiving situation, aligning with psychiatric nursing principles for maternal mental health crisis intervention.

Choice D reason: Reassuring about milestones is dismissive of the mother’s grief and depression, potentially minimizing her distress. Assessing for harmful thoughts ensures safety, addressing the immediate risk of her emotional state. False reassurance is untherapeutic, making this incorrect for responding to her depression.

A. Poor self-esteem. B. A sense of loss. C. Feelings of frustration. D. A lack of intimate relationships.

Correct Answer is B

Explanation

Choice A reason: Poor self-esteem may contribute to depression but is less specific than the cumulative losses (divorce, job, breakup) driving the client’s self-injury. Loss directly ties to these recent events, making self-esteem a secondary factor and incorrect for the primary source of current depressive feelings.

Choice B reason: A sense of loss from divorce, job loss, and a recent breakup is the most likely source of the client’s depression, culminating in self-injury. These cumulative losses trigger grief and hopelessness, aligning with psychiatric evidence for situational depression, making this the correct choice.

Choice C reason: Feelings of frustration may accompany loss but are less central than the grief from multiple losses (divorce, job, breakup). Loss better captures the emotional impact of these events, making frustration a less precise and incorrect choice for the primary depression source.

Choice D reason: Lack of intimate relationships is a consequence of the breakup but less comprehensive than the broader sense of loss from multiple life events. Loss encompasses divorce, job, and breakup, making this narrower and incorrect for the primary source of the client’s depressive state.

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Naxlex Comprehensive Predictor Exams

The mother of an infant with profound mental and physical disabilities tells the nurse how depressed she is because she realizes that her child will never achieve normal growth and development milestones. How should the nurse respond to this mother?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

A client with a major depressive disorder is admitted to the inpatient psychiatric unit. Which intervention should the nurse use to demonstrate support of the client?

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfiram. Which information should the client provide to acknowledge understanding?

The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?

Which short-term outcome should the nurse include in the initial treatment plan for a client with dementia?

A client at the mental health center reports difficulty concentrating at work, feeling very tired during the day, and sleeping 4 to 5 hours at night. To further assess for depression, which question is most important for the nurse to ask?

The nurse is planning the care for a client who is hospitalized with a bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? (Select all that apply)