A nurse conducts a home health or outpatient visit with an adult client. During the interaction:

• The client appears anxious, withdrawn, and hesitant to speak openly
• There are visible bruises in different stages of healing
• When asked privately, the client discloses experiencing emotional and/or physical abuse by a partner
• The client does not want police involvement at this time
• There is no immediate life-threatening injury reported
• The client expresses uncertainty and emotional distress, but is open to support

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

During the admission assessment to the mental health unit, a client reports that the people at the office, where the client works, are antagonistic, and the client is thinking of shooting the supervisor. The client asks the nurse not to reveal this to anyone else. The nurse immediately notifies the client's therapist and other team members of the client's thoughts. The therapist then calls the client's supervisor and shares the client's thoughts about shooting the supervisor. Which outcome is best based on the action of the nurse?

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

The nurse plans to use role-playing as a therapeutic measure. Which individual is most likely to benefit from this type of therapeutic intervention?

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?

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 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?

A client who is an alcoholic receives a prescription for disulfiram 500 mg by mouth (PO) daily. Which instruction should the nurse provide to this client?

A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and lack of motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

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?

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