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 A

Explanation

A. Returning to a previous level of functioning is essential for someone hospitalized due to an overdose as it ensures their safety and stability.
B. Identifying personal traits might be a part of therapy but is not the primary goal immediately after an overdose.
C. While exercise can be beneficial, it's not the primary concern right after a suicide attempt.

D. Discussing relationship needs is important but not the immediate priority after a suicide attempt.

A. Erythema of the localized lesions. B. Evidence of patches of lost hair. C. Episodic complaints of pruritus. D. Ecchymotic blood accumulations.

Correct Answer is D

Explanation

Rationale for A: Erythema of localized lesions may indicate an inflammatory condition or infection, which could suggest that the hair loss is disease-related.

Rationale for B: Evidence of patches of lost haircan be due to cosmetic products or abuse hence not conclusive

Rationale for C: Episodic complaints of pruritus could indicate an allergic reaction or infestation, which suggests a possible disease-related cause for the hair loss.

Rationale for D: Ecchymotic blood accumulations suggest trauma to the scalp.

C. Episodic complaints of pruritus (itching) might suggest irritation but do not conclusively indicate the hair loss is not disease-related.
D. Ecchymotic blood accumulations indicate bruising but are not typically associated with hair pain or loss.

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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 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?

Correct Answer is A

Explanation

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease-related?

Correct Answer is D

Explanation

A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first?

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?

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?

A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?

The nurse is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview?

A male client tells the nurse that he does not want to take the atypical antipsychotic drug olanzapine because of the side effects he experienced when he took the drug for a year. Which experience is most likely related to taking olanzapine?

The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in-depth with the client based on this screening tool?