The mental health unit nurse completes the admission assessment for a depressed adolescent client with suicidal ideation. The client reports becoming angry with a sibling, so the client took a handful of pills. Which goal is most important for the nurse to establish with this client?

Identify three effective ways to cope with feelings.

Attend at least 2 group sessions daily on the unit.

Interact positively with the staff on the unit.

Verbally express anger towards family.

Answer and Explanation

The Correct Answer is A

Choice A reason: Identifying effective coping strategies is critical for an adolescent with suicidal ideation triggered by anger, as it addresses the root cause of the suicide attempt. This goal promotes emotional regulation and prevents future self-harm, aligning with psychiatric nursing priorities for suicide risk management.

Choice B reason: Attending group sessions supports socialization but does not directly address the client’s suicidal behavior or emotional triggers. Coping strategies are more critical to prevent recurrence of self-harm, making this goal less important than learning to manage feelings effectively in this context.

Choice C reason: Positive staff interaction fosters therapeutic alliance but does not target the client’s suicidal ideation or anger management. Developing coping skills is more critical to address the underlying emotional dysregulation, making this goal secondary to learning effective strategies for handling intense feelings.

Choice D reason: Expressing anger towards family may escalate conflict without resolving the client’s suicidal behavior. Teaching coping strategies is more important to manage emotions safely, preventing further self-harm. This goal is less therapeutic and potentially harmful, making it incorrect for priority care planning.

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Correct Answer is B

Explanation

Choice A reason: Current weight is relevant for monitoring but not critical before starting sertraline. Medication history is more important to avoid drug interactions, as sertraline affects serotonin levels. Weight changes may occur during treatment, but they are not a primary concern for initiation, making this incorrect.

Choice B reason: Medication history is critical before starting sertraline to identify potential drug interactions, especially with MAOIs, SSRIs, or other serotonergic drugs, which can cause serotonin syndrome. This ensures safe prescribing, aligning with psychopharmacology guidelines, making it the most important information to obtain prior to initiation.

Choice C reason: Heart disease history is relevant but less critical than medication history for sertraline, which has minimal cardiac effects. Drug interactions pose a greater immediate risk, particularly with serotonergic agents. This choice is secondary, as cardiac concerns are not the primary consideration for sertraline initiation.

Choice D reason: Familial history of mental illness may guide diagnosis but is not essential for starting sertraline. Medication history directly impacts safety due to interaction risks. Family history is less urgent, making this incorrect compared to the immediate need to assess current medications for safe antidepressant use.

A. Tries to run the unit, telling everyone what to do and when to do it. B. Is openly hostile to others for no apparent reason. C. Repeatedly tries to commit suicide. D. Talks to voices only the client can hear.

Correct Answer is B

Explanation

Choice A reason: Controlling the unit reflects grandiosity or mania, not paranoia. Paranoid clients are more likely to exhibit hostility due to perceived threats. This behavior is less typical of paranoia’s suspicious nature, making it incorrect for expected behavior in a paranoid client.

Choice B reason: Open hostility for no apparent reason is common in paranoia, as clients misinterpret others’ actions as threatening due to delusional beliefs. This aligns with psychiatric descriptions of paranoid behavior, making it the most expected behavior for a client with paranoia during assessment.

Choice C reason: Repeated suicide attempts are associated with depression or borderline personality disorder, not primarily paranoia. Hostility from perceived threats is more characteristic of paranoia, making suicide attempts less expected and incorrect for the typical behavior in this client.

Choice D reason: Talking to voices suggests hallucinations, more common in schizophrenia with auditory hallucinations than in paranoia alone. Hostility from suspicion is a more direct paranoid behavior, making this incorrect, as hallucinations are not the primary expected feature of paranoia.

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The mental health unit nurse completes the admission assessment for a depressed adolescent client with suicidal ideation. The client reports becoming angry with a sibling, so the client took a handful of pills. Which goal is most important for the nurse to establish with this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?

Correct Answer is B

Explanation

The nurse is assessing a client with paranoia. Which behavior can this client be expected to exhibit?

Correct Answer is B

Explanation

The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?

A young female client is admitted to the emergency department because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record (EMR) as the client’s chief concern?

The nurse is providing teaching to a client and family about schizophrenia before discharge from an inpatient facility. The nurse should instruct the family to notify the healthcare provider when which behavior is observed?

A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?

The mother of an infant with profound mental and physical disabilities tells the nurse how depressed she is because she realizes that her child will never achieve normal growth and development milestones. How should the nurse respond to this mother?

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?