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 D

Explanation

A. Involving another nurse might not necessarily address the client's guarded and suspicious behavior.
B. Documenting the behavior is important for the client's records, but it doesn't address the immediate need for assessment.
C. Postponing the interview might not resolve the client's guarded behavior and could delay necessary assessment.
D. Attempting to ask the client simple questions allows for a non-threatening approach and might gradually build rapport, encouraging the client to engage in conversation.

A. Isolate the client from other clients. B. Administer a PRN sedative. C. Escort the client to a private area. D. Avoid recognizing the behavior.

Correct Answer is C

Explanation

A. Isolating the client might exacerbate feelings of social exclusion and isn't the best approach for managing echolalia.
B. Administering a sedative should not be the initial response to echolalia unless the behavior poses immediate harm to the client or others.
C. Escorting the client to a private area can help reduce the annoyance to other clients without isolating or punishing the individual.
D. Avoiding recognition of the behavior doesn't address the issue and might negatively impact the therapeutic relationship.

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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 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?

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?

Correct Answer is C

Explanation

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?

In conducting the initial assessment of a preoperative client, the nurse notes that the client's home medications include the monoamine oxidase (MAO) inhibitor phenelzine. Because of this client's medication history, which assessment finding is most important for the nurse to monitor?

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 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 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 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?

The nurse is conducting client assessments in an outpatient psychiatric clinic. Which client finding is characteristic of illness anxiety disorder?

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?