The nurse continues caring for the client

Nurses' Notes

• Diagnosis: depression and post-traumatic stress disorder Diphenhydramine 12.5 mg PO every night at sleep (HS) • Buspirone hydrochloride 7.5 mg PO twice a day

During the conversation with the client, the nurse documents a statement by the client about wishing she had died in the crash.

Choose the most likely options for the information missing from the statement by selecting from the list of options provided.

The statement by the client represents and should be followed up with an

Answer and Explanation

The Correct Answer is ["suicidal ideation"," assessment of risk factors for suicide"]

In the context of mental health care, a statement by a client expressing a wish to have died in a traumatic event is indicative of suicidal ideation. This is a serious concern and warrants immediate and careful attention from the healthcare provider. The appropriate response involves conducting a thorough assessment of risk factors for suicide, which may include evaluating the client's mental health history, current stressors, support systems, and any previous suicide attempts or self-harm behavior. This assessment is crucial in determining the level of risk and the need for potential interventions, which may range from close monitoring to emergency psychiatric evaluation. It is essential for healthcare professionals to approach such situations with sensitivity, providing support and ensuring the safety of the client as a priority.

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

Explanation

A. Restricting visitors may exacerbate feelings of isolation and may not be therapeutic for the adolescent client who is depressed.
B. Reinforcing statements regarding a will to live and realistic plans for the future can provide hope and motivation for the adolescent to engage in treatment and recovery.
C. Understanding the client's suicide plan is crucial for assessing risk and planning appropriate interventions to ensure safety.
D. Encouraging the client to discuss thoughts and feelings promotes open communication and allows the adolescent to express emotions, which can be therapeutic and supportive in managing depression.
E. While limiting excessive screen time, including video games, may be beneficial for overall well-being, it may not directly address the underlying issues contributing to the adolescent's depression and may be less relevant in the immediate plan of care.

A. Responds with illogical answers to questions. B. Admits to frequently thinking about committing suicide. C. Describes times of depression followed by feelings of euphoria. D. Exhibits compulsive, ritualistic behaviors.

Correct Answer is A

Explanation

A. Responding with illogical answers to questions is characteristic of schizophrenia, particularly during periods of psychosis when the client may experience disorganized thinking and impaired reality testing.
B. Admitting to frequently thinking about committing suicide is not specific to schizophrenia and may occur in various mental health conditions, such as depression or bipolar disorder.
C. Describing times of depression followed by feelings of euphoria suggests a mood disorder, such as bipolar disorder, rather than schizophrenia.
D. Exhibiting compulsive, ritualistic behaviors may be seen in obsessive-compulsive disorder (OCD) but is not typically characteristic of schizophrenia. Schizophrenia is primarily characterized by positive symptoms (such as hallucinations and delusions), negative symptoms (such as blunted affect and social withdrawal), and cognitive symptoms (such as disorganized thinking and impaired executive function).

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Naxlex Comprehensive Predictor Exams

Which intervention(s) should the nurse include in the plan of care for an adolescent client who is depressed? Select all that apply.

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

Explanation

The nurse is performing the admission assessment for a client with schizophrenia in an acute care inpatient facility. The nurse should identify which observed behavior is characteristic of schizophrenia?

Correct Answer is A

Explanation

The nurse is caring for a client Exhibits In order to help the client disclose a situation that is upsetting to him, what therapeutic communication tools could the nurse use? Select all that apply.

A client requests permission for the spouse to remain in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. Which action should the nurse take?

A male client with a recent diagnosis of bipolar disorder takes lithium carbonate daily. The client informed the school nurse of the desire to live away from home to attend college after graduating in one month. Which information is most important for the nurse to provide the client and his family?

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?

Which individual should the nurse consider at highest risk for suicide?

A client who is an alcoholic receives a prescription for disulfiram 500 mg by mouth (PO) daily. Which instruction should the nurse provide to this client?

An adult female client is brought to the Emergency Center after fainting at work. The nurse completes an assessment of the client and identifies caregiver role strain as a nursing problem. Which information best supports this problem?