The nurse accepts a client who is being transferred to the mental health unit and understands that the client is distractible and is exhibiting a decreased ability to concentrate. The nurse has only 15 minutes to talk with the client. To develop a treatment plan for this client, which assessment is most important for the nurse to obtain?

Mental status examination.

History of substance use.

Medication compliance.

Motivation for treatment.

Answer and Explanation

The Correct Answer is A

Choice A reason: A mental status examination (MSE) assesses cognition, mood, and thought processes, providing critical data on distractibility and concentration in a short timeframe. This guides the treatment plan for a client with these symptoms, aligning with psychiatric assessment protocols, making it the most important initial assessment.

Choice B reason: Substance use history is relevant but less urgent than an MSE, which directly evaluates current cognitive and emotional state. In 15 minutes, MSE provides immediate data for treatment planning, making substance history secondary and incorrect for the most critical initial assessment.

Choice C reason: Medication compliance informs treatment but does not address the client’s current distractibility and concentration issues as directly as an MSE. The MSE offers real-time insight into symptoms, guiding the plan, making compliance less urgent and incorrect for the primary assessment in this timeframe.

Choice D reason: Motivation for treatment is important but secondary to understanding the client’s current mental state via MSE, which informs immediate interventions for distractibility. Limited time prioritizes objective assessment, making motivation less critical and incorrect for the most important initial treatment planning step.

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Correct Answer is C

Explanation

Choice A reason: Confronting delusions directly can increase agitation and disrupt therapeutic rapport in schizophrenia. Ensuring a safe environment addresses potential risks from delusional behavior without challenging beliefs, aligning with psychiatric nursing principles for managing psychosis, making this incorrect for the care plan.

Choice B reason: Activity therapy supports socialization but does not address the immediate safety needs posed by the client’s delusion. Ensuring a safe environment prevents harm related to grandiose beliefs, making this intervention secondary and incorrect compared to prioritizing safety in acute schizophrenia management.

Choice C reason: Ensuring a safe environment is critical for a client with schizophrenia expressing delusions, as grandiose beliefs may lead to risky behaviors. This intervention minimizes harm while supporting therapeutic engagement, aligning with safety-first psychiatric care principles, making it the most appropriate care plan inclusion.

Choice D reason: Leading the client to seclusion is overly restrictive and unwarranted based solely on a delusion, which is not inherently dangerous. Ensuring safety through environmental management is less invasive and more therapeutic, making seclusion incorrect for managing this client’s delusional statement.

A. Poor self-esteem. B. A sense of loss. C. Feelings of frustration. D. A lack of intimate relationships.

Correct Answer is B

Explanation

Choice A reason: Poor self-esteem may contribute to depression but is less specific than the cumulative losses (divorce, job, breakup) driving the client’s self-injury. Loss directly ties to these recent events, making self-esteem a secondary factor and incorrect for the primary source of current depressive feelings.

Choice B reason: A sense of loss from divorce, job loss, and a recent breakup is the most likely source of the client’s depression, culminating in self-injury. These cumulative losses trigger grief and hopelessness, aligning with psychiatric evidence for situational depression, making this the correct choice.

Choice C reason: Feelings of frustration may accompany loss but are less central than the grief from multiple losses (divorce, job, breakup). Loss better captures the emotional impact of these events, making frustration a less precise and incorrect choice for the primary depression source.

Choice D reason: Lack of intimate relationships is a consequence of the breakup but less comprehensive than the broader sense of loss from multiple life events. Loss encompasses divorce, job, and breakup, making this narrower and incorrect for the primary source of the client’s depressive state.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

On admission to the mental health unit, a client diagnosed with schizophrenia tells the nurse, "I am the son of God." Based on this statement, which intervention should the nurse include in this client's plan of care?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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 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?

An adult female client with bipolar disorder is seen in the outpatient psychiatric clinic and tells the nurse that she is thinking of harming her sister. Which action is most important for the nurse to take?

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease related?

The nurse is performing intake interviews at a psychiatric clinic. A female client with a known history of drug abuse reports that she had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction?

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 at the mental health center reports difficulty concentrating at work, feeling very tired during the day, and sleeping 4 to 5 hours at night. To further assess for depression, which question is most important for the nurse to ask?