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 C

Explanation

A. Shifting attention from self to others might strain the individual further as they might not have the emotional energy for it.
B. Relaxation without addressing underlying issues won't help in managing depression and might exacerbate the situation.
C. Focusing on small achievable tasks helps in breaking down overwhelming problems into manageable parts, aiding in a sense of accomplishment.
D. Ventilating emotions might be beneficial, but solely relying on this strategy might not address the core issue of handling responsibilities.

A. White blood cell count. B. 24-hour urinary output. C. Blood sugar level. D. Current vital signs.

Correct Answer is D

Explanation

A. White blood cell count might be relevant for other conditions but is not specific to NMS.
B. 24-hour urinary output might help evaluate kidney function but is not specific to NMS.
C. Blood sugar level might be important but is not the primary indicator of NMS.
D. Vital signs, such as temperature, blood pressure, heart rate, and respiratory rate, are crucial in assessing for NMS as it typically presents with changes in these parameters.

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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

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?

Correct Answer is C

Explanation

A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?

Correct Answer is D

Explanation

A client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. Which intervention is best for the nurse to implement?

When responding to a call light, the nurse finds a client with aggressive behaviors pacing and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?

A client with borderline personality disorder tells the nurse, "You are the best nurse on the unit! The other nurses don't care about me the way you do." Which response should the nurse provide to this client?

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?

The nurse documents that a male client with schizophrenia is delusional. Which statement by the client confirms this assessment?

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?

The nurse is performing the admission assessment for a client with schizophrenia in an acute care inpatient facility. The nurse should identify which observed behavior is characteristic of schizophrenia?