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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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. The client's symptoms, including a laterally contracted position and perception of body contortion, suggest acute dystonia, a known side effect of antipsychotic medications like risperidone. Administering an anticholinergic such as benztropine can help alleviate these symptoms.
B. Offering a hot pack for muscle spasms may provide some relief for generalized muscle discomfort but would not specifically address the dystonic reaction.
C. Directing the client to occupational therapy may be beneficial for overall treatment but does not address the immediate need to alleviate acute dystonic symptoms.
D. Thioridazine is an antipsychotic medication but is not typically used as a first-line treatment for acute dystonia. Administering benztropine, an anticholinergic, would be more appropriate for dystonia associated with risperidone use.

A. Share personal values to put the client at ease. B. Ask questions in a vague, non-specific format. C. Begin with questions that are less sensitive in nature. D. Get the most difficult questions over with first.

Correct Answer is C

Explanation

A. Sharing personal values may blur professional boundaries and could potentially influence the client's responses, which is not appropriate in a therapeutic setting.
B. Asking questions in a vague, non-specific format may not yield accurate or detailed information about the client's suicidal ideations.
C. Beginning with less sensitive questions allows the client to gradually build trust and rapport with the nurse before addressing more sensitive topics like suicidal ideation.
D. Getting the most difficult questions over with first may overwhelm the client and hinder the development of trust and rapport, which are crucial for effective communication in addressing sensitive topics like suicidal ideation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Which is the best approach for the nurse to use when interviewing a client about suicidal ideations?

Correct Answer is C

Explanation

The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?

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

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?

The nurse has received a new prescription for the client to begin taking sertraline. Prior to administering the initial dose of sertraline, it is most important for the nurse to obtain which information?

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?

The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessment?

During a family group meeting, the client's daughter tells the group, "I hope I didn't cause Mom to be depressed." Which response is best for the nurse to provide?