The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?

Participates in individual and group therapy.

Demonstrates effective ways to cope with anxiety.

Takes all antianxiety medications as prescribed.

Learns methods of relaxation to reduce anxiety.

Answer and Explanation

The Correct Answer is B

A.   Participating in individual and group therapy is important for overall mental health, but the immediate focus is on addressing the self-harming behavior.
B.   Demonstrating effective ways to cope with anxiety is the most important outcome to address the client's self-harming behavior and promote healthier coping mechanisms.
C. Taking all antianxiety medications as prescribed is important but may not directly address the client's self-harming behavior.
D.   Learning methods of relaxation is valuable, but the most immediate concern is preventing self-harm. The client should demonstrate effective ways to cope with anxiety to reduce the risk of self-injury.

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Correct Answer is A

Explanation

A. Allowing the client to rest and sleep is a priority, as sleep deprivation can exacerbate symptoms of depression. Addressing immediate physical needs is crucial.
B. Planning for discharge can be addressed later in the treatment process; the immediate focus should be on ensuring the client's basic needs are met.
C. Encouraging verbalization of feelings is important but should not take precedence over addressing the client's sleep deprivation.
D. Ensuring the client attends groups addressing coping skills for dealing with depression is valuable but may be addressed after the client has had sufficient rest. Prioritizing sleep helps address the most immediate concern.

A. Determine the client’s reason for attempting suicide. B. Obtain the client’s serum hydrocodone/acetaminophen level. C. Encourage the client to increase fluid intake. D. Observe the client for further narcotic effects.

Correct Answer is D

Explanation

A. Determine the client’s reason for attempting suicide: While assessing suicidal intent is important, the immediate priority is ensuring the client's physiological stability. Suicidal ideation can be addressed once the client is medically stable.

B. Obtain the client’s serum hydrocodone/acetaminophen level: This may be ordered, but it is not the highest priority. Clinical observation is more urgent, especially because naloxone has a shorter half-life than many opioids, including hydrocodone.

C. Encourage the client to increase fluid intake: This is not a priority intervention in the immediate post-overdose period and does not address the risk of opioid rebound toxicity.

D. Observe the client for further narcotic effects: Naloxone has a short duration of action (typically 30–90 minutes), whereas hydrocodone has a longer half-life. Once naloxone wears off, respiratory depression and sedation can recur. Continuous monitoring is critical to ensure timely re-administration if opioid effects return.

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The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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