The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?

Explain that these beliefs are related to her illness.

Explain that distrust is related to feeling anxious.

Initiate short, frequent contacts with the client.

Offer to keep the belongings at the nurse's desk.

Answer and Explanation

The Correct Answer is C

(A) Explain that these beliefs are related to her illness: While it is important to educate the client about their illness, directly challenging their delusions may increase distrust and anxiety. This approach might make the client feel misunderstood and less likely to trust the nurse.

(B) Explain that distrust is related to feeling anxious: This explanation might not be well-received by the client and could be perceived as dismissive of their concerns. It may not effectively address the client’s immediate need for trust and reassurance.

(C) Initiate short, frequent contacts with the client: This approach helps build trust through consistent and reliable interactions. It allows the nurse to establish a rapport without overwhelming the client, thereby promoting a sense of safety and trust. Regular, brief interactions can help the client feel more comfortable and secure.

(D) Offer to keep the belongings at the nurse’s desk: This action might be perceived as an attempt to take control of the client’s belongings, which could reinforce their delusions and decrease trust. It is important to respect the client’s need to keep their belongings close to them.

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Correct Answer is ["C","D","E"]

Explanation

A) Grandiosity is not typically associated with postpartum depression. Instead, it is more commonly seen in conditions such as mania or bipolar disorder. This finding would not be consistent with postpartum depression.

B) Compulsive behavior may occur in various mental health conditions, but it is not a core symptom of postpartum depression. This symptom would need further evaluation to determine its relevance in this context.

C) Sadness is a hallmark symptom of postpartum depression. Clients often report feelings of intense sadness and hopelessness, making this a key finding in the assessment.

D) Poor concentration is commonly observed in postpartum depression. Many clients experience difficulties with focus and decision-making, which can be distressing and interfere with daily functioning.

E) Disrupted sleep is another significant symptom associated with postpartum depression. Clients may experience insomnia or altered sleep patterns, which can exacerbate feelings of fatigue and sadness.

A. Impaired comfort. B. Risk for injury. C. Ineffective breathing pattern. D. Ineffective coping.

Correct Answer is C

Explanation

A) Impaired comfort is a relevant concern, but it is not the highest priority in the context of a potentially life-threatening situation such as aspiration of a caustic material. While comfort is important, it is secondary to immediate safety and physiological needs.

B) Risk for injury is a general concern in many situations, but in this specific case, it does not address the acute medical implications of the aspiration of caustic material. While injury could occur, the focus should be on the immediate effects of the incident.

C) Ineffective breathing pattern is the highest priority nursing problem. Aspiration of caustic material can lead to severe respiratory complications, including airway obstruction, chemical pneumonitis, and other respiratory distress. Ensuring the client has adequate ventilation and monitoring for signs of respiratory distress are critical nursing interventions that take precedence over other concerns.

D) Ineffective coping is important to address, particularly given the context of a suicide attempt; however, it is not as immediate as the potential life-threatening consequences of aspiration and ineffective breathing. The client’s physical safety must be prioritized before addressing psychological issues.

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The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client with postpartum depression for changes in the mood and cognitive state. Which subjective finding(s) should the nurse identify that are consistent with postpartum depression? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

A client is admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt. Which nursing problem has the highest priority?

Correct Answer is C

Explanation

The nurse is providing care for a client diagnosed with a borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the nurse use when changing this client's dressings?

A client with schizophrenia receives a prescription for fluphenazine. Which instruction is most important for the nurse to include when teaching the client about this drug?

During admission to the psychiatric unit, a female client is extremely anxious and expresses that she is worried about the sun coming up the next day. Which intervention is most important for the nurse to implement during the admission process?

The nurse is preparing a client for discharge who has been taking alprazolam long-term for generalized anxiety disorder (GAD). When evaluating the client's understanding of the discharge teaching, which statement made by the client shows awareness of the most important self-care goal?

An older adult woman who lives in a long-term mental health facility has a history of taking belongings from other clients' rooms when she becomes agitated. The client is found placing these items in the same closet on the unit. Which action should the nurse take?

When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client's record should the nurse review?