The home health aide reports to the practical nurse that the client has been trying to give away possessions.

When the nurse asks the client about this behavior, the client says, “With my spouse dead, there’s no reason for me to go on.”. What is the best priority response by the nurse?

“Tell me more about how you’re feeling.”.

“You’re not thinking of killing yourself, are you?”

“Have you thought of therapy?”

“Let’s discuss some coping strategies.”.

Answer and Explanation

The Correct Answer is A

Choice A rationale
When a client expresses feelings of hopelessness and exhibits behaviors such as giving away possessions, it is crucial for the nurse to further explore these feelings. Asking the client to elaborate on their feelings allows the nurse to gather more information and assess the severity of the client’s emotional state. It also communicates to the client that the nurse is there to listen and provide support.
Choice B rationale
While it is important to assess for suicidal ideation in clients expressing hopelessness, asking directly, “You’re not thinking of killing yourself, are you?” can come across as confrontational and may cause the client to become defensive or close off.
Choice C rationale
Suggesting therapy is a potential intervention, but it is not the best initial response. The immediate priority is to assess the client’s emotional state and risk for self-harm.
Choice D rationale
Discussing coping strategies may be beneficial once the client’s immediate emotional state and safety have been addressed. However, it is not the best initial response when a client is expressing intense feelings of hopelessness.

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Correct Answer is C

Explanation

Choice A rationale
While it’s important to understand the circumstances leading to the assault, this statement does not require immediate attention from the nurse. It’s more related to the incident itself rather than the patient’s current condition.
Choice B rationale
Expressing hatred towards others can be a sign of emotional distress, but it does not require immediate medical attention.
Choice C rationale
Tingling in the fingers can be a sign of reduced blood circulation, which could be a result of the restraints. This requires immediate attention to prevent further complications.
Choice D rationale
While it’s important to address legal threats, this statement does not require immediate medical attention.

A. 0.2 ml. B. 0.4 ml. C. 0.6 ml. D. 0.8 ml.

Correct Answer is B

Explanation

Step 1 is to determine the amount of medication to administer. The order is for Haldol 2mg IM stat. The available medication is Haldol 5mg/ml. To find out how many ml’s to administer, you would divide the ordered dose by the available dose. So, 2mg ÷ 5mg/ml = 0.4 ml.

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The home health aide reports to the practical nurse that the client has been trying to give away possessions. When the nurse asks the client about this behavior, the client says, “With my spouse dead, there’s no reason for me to go on.”. What is the best priority response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adult patient assaulted another patient and was subsequently restrained. One hour later, which statement by the restrained patient requires the nurse’s immediate attention?

Correct Answer is C

Explanation

Haldol 2mg IM stat has been ordered for the agitated client. Haldol is available in 5mg/ml. How many ml’s will you administer?

Correct Answer is B

Explanation

Upon entrance into a mental health care system, clients are thoroughly assessed, and this is followed by the development of a mental health treatment plan assessment. Which of the following are purposes of the treatment plan? (Select all that apply)

A patient has been admitted due to severe depression. What symptoms should the nurse anticipate during the assessment?

True or False: A person with severe depression may sleep excessively.

What expected outcomes should the nurse document for a client diagnosed with a depressive disorder? (Select all that apply)

What should be the first step for a nurse when communicating with an angry patient?

Upon entering a mental health care system, clients undergo a thorough assessment, followed by the creation of a mental health treatment plan. What are the objectives of this treatment plan? (Select all that apply.)

During the mental status examination, the nurse observes that the client rapidly shifts from one idea to another related thought. Which disordered thinking process is the client displaying?

A nurse is providing a community health education class about suicide prevention. Which of the following should the nurse identify as risk factors for suicide? (Select all that apply).

The home health aide reports to the practical nurse that the client has been trying to give away possessions.

When the nurse asks the client about this behavior, the client says, “With my spouse dead, there’s no reason for me to go on.”. What is the best priority response by the nurse?