An adolescent tells the school nurse, "My friend threatened to take an overdose of pills." The nurse talks to the friend who verbalized the suicide threat. What is the most critical question for the nurse to ask?

"Why do you want to kill yourself?"

"Do you have access to medications?"

"Have you been taking drugs and alcohol?"

"Did something happen with your parents?"

Answer and Explanation

The Correct Answer is B

A) Incorrect. While understanding the reasons behind the suicidal thoughts is important, in this immediate situation, assessing access to means (medications) is crucial.

B) Correct. This question assesses the immediate risk by determining if the friend has access to the means (medications) to carry out the overdose.

C) Incorrect. While substance use is a risk factor, it may not directly address the immediate threat of overdose with pills.

D) Incorrect. While family issues can contribute to emotional distress, the most pressing concern is the immediate risk of overdose.

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Correct Answer is D

Explanation

A. "Lab work is only needed at the start of taking the medication." This statement is incorrect. Regular monitoring of lithium levels and kidney function through lab work is crucial for ensuring the medication's effectiveness and preventing potential toxicity.

B. "Once I feel better, I will not need to take this medication anymore." This statement is incorrect. Lithium is typically prescribed for long-term maintenance in bipolar disorder to prevent relapses and stabilize mood.

C. "There is a chance I may become addicted to this medication." This statement is incorrect. Lithium is not addictive. It is a mood stabilizer used to manage bipolar disorder.

D. "I need to be aware of situations that may cause dehydration." This statement demonstrates an understanding of an important consideration with lithium. Dehydration can lead to an increase in lithium levels in the body, potentially leading to toxicity. It's important for clients taking lithium to stay well hydrated and be cautious in situations that may lead to dehydration.

A. "This therapy helps you learn to think more positively, and thereby reduce depressive thoughts and symptoms." B. "In this therapy, you will explore past events and analyze how these events have affected your behavior and thoughts." C. "This type of therapy focuses on how you use defense mechanisms to feel more comfortable and content." D. "The purpose of this therapy is to determine how to get psychological needs met through interpersonal relationships."

Correct Answer is A

Explanation

A. "This therapy helps you learn to think more positively, and thereby reduce depressive
thoughts and symptoms." Cognitive behavioral therapy (CBT) aims to identify and challenge negative thought patterns and replace them with more positive and realistic thinking, which can help alleviate symptoms of depression.

B. "In this therapy, you will explore past events and analyze how these events have affected your behavior and thoughts." This description is more characteristic of psychodynamic therapy, not cognitive behavioral therapy.

C. "This type of therapy focuses on how you use defense mechanisms to feel more comfortable and content." This description aligns more with psychodynamic therapy, not cognitive behavioral therapy.

D. "The purpose of this therapy is to determine how to get psychological needs met through
interpersonal relationships." This statement does not accurately describe cognitive behavioral
therapy, which primarily focuses on identifying and changing maladaptive thought patterns and behaviors.

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An adolescent tells the school nurse, "My friend threatened to take an overdose of pills." The nurse talks to the friend who verbalized the suicide threat. What is the most critical question for the nurse to ask?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has been prescribed lithium for long-term maintenance of bipolar disorder diagnosis. Which statement by the client shows an understanding of the medication?

Correct Answer is D

Explanation

A client diagnosed with major depressive disorder is considering cognitive behavioral therapy. The client asks the nurse how this therapy would help alleviate depressive thoughts. What is the best response by the nurse?

Correct Answer is A

Explanation

The nurse is obtaining the mental health history of a newly admitted client diagnosed with schizophrenia. The client's family reports the client is hearing voices and cannot stay focused on the topic of a discussion. Which thought disturbance is the client demonstrating?

Which of the following is the most therapeutic response by the nurse when a client states, "I no longer need my medication since I do not hear voices"?

During the admission process, an elderly client is asked to present their license for identification purposes. The client gives the admission personnel their glasses. This is an example of which of the following symptoms of dementia?

A female client staggers to day treatment smelling strongly of alcohol. She uses the defense mechanism "rationalization" when approached by the nurse and questioned about her recent alcohol consumption. How is this expressed?

A client is showing early signs of dementia. The client's spouse asks, "What may I expect next?" What is the nurse's best response?

A client is admitted to the hospital for alcohol intoxication. The family reports that he is a heavy drinker and has been admitted several times for alcohol detoxification. When can the nurse expect to observe the first symptoms of withdrawal?

The nurse is admitting a client with the diagnosis of schizophreniform disorder. What should the nurse expect to find?