Following the visit, what are appropriate actions for the nurse? Select all that apply.

Mail education items to the home for batterer treatment options

Provide referrals from the physician for mental health services

Follow up with the client in a few weeks

Call the police as a mandatory reporter

Document verbatim statements about the abuse

Answer and Explanation

Correct Answer : B,C,E

A.   Mailing education items to the home for batterer treatment options might not be appropriate without the client's consent or discussion.
B.   Providing referrals for mental health services aligns with addressing the client's needs.
C.   Following up with the client in a few weeks ensures continuity of care and monitoring of the client's progress.
D.   Calling the police as a mandatory reporter might be necessary if there's an immediate threat, but it's not mentioned in the scenario.
E.   Documenting verbatim statements about the abuse is crucial for accurate record-keeping and legal purposes.

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Correct Answer is B

Explanation

A. Both the nurse and therapist took action to ensure safety; therefore, reprimanding might not be appropriate.
B. The best outcome is an educational approach for the team to understand appropriate information sharing in cases of potential harm to others while maintaining patient confidentiality.
C. The nurse's immediate notification was based on safety concerns, which may take precedence over obtaining informed consent.
D. The therapist's action aimed at ensuring safety but might have breached confidentiality without explicit consent.

A. Provide a quiet room away from the recreational area. B. Acquaint the client with the rules of the unit. C. Ensure that the client eats a well-balanced diet. D. Introduce the client to other clients with a similar diagnosis.

Correct Answer is A

Explanation

A. Providing a quiet room is important. This is because individuals with PTSD are often hypersensitive to noise and other stimuli, which can trigger flashbacks or other
symptoms. A quiet environment can help to reduce anxiety and promote relaxation.
B. Acquainting the client with the unit rules is important, but connecting the client with peers who understand their experiences can be more therapeutic initially.
C. Ensuring a well-balanced diet is essential but might not be the priority in the immediate plan of care for someone newly admitted with PTSD.
D. Introducing the client to others with similar diagnoses helps foster a sense of belonging.
However, this is a long-term rather than an immediate intervention.

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Following the visit, what are appropriate actions for the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client with post-traumatic stress disorder (PTSD) is admitted to the psychiatric unit. Which intervention is most important for the nurse to include in this client's plan of care?

Correct Answer is A

Explanation

A female college student is admitted to the mental health unit following a drug overdose. The student tells the nurse that she took 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?

A young female client is admitted to the emergency room because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record as the client's chief complaint?

The nurse is planning the care for a client who is hospitalized with 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.)

The mother of an 8-month-old 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?

An antidepressant medication is prescribed for a client who reports sleeping only four hours in the past two days and a weight loss of nine pounds within the last month. Which client goal is most important to achieve within the first three days of treatment?

The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?