The nurse is observing the interaction between a mother and schizophrenic son. The son states, "The man visiting me said you went on vacation without me." The mother replied, "There is no man, you are just making that up." When interacting with the mother privately, which reply from the mother would the nurse suggest?

"I am not on vacation. I am here with you."

"How can I go on vacation. I do not have any money."

"Stop saying that. You know better. No one told you that."

"Just forget about that and let's talk about something else."

Answer and Explanation

The Correct Answer is A

A. "I am not on vacation. I am here with you." This response calmly reassures the client by affirming the mother’s presence, which helps address the son’s confusion without directly challenging his perception.

B. "How can I go on vacation? I do not have any money." This response could increase confusion and does not address the son's needs effectively. It could also lead to unnecessary discussions that might not be helpful.

C. "Stop saying that. You know better. No one told you that." This response is dismissive and confrontational, which may exacerbate the son’s distress and could damage the therapeutic relationship.

D. "Just forget about that and let's talk about something else." This response avoids addressing the son’s concerns, which can make him feel dismissed and not listened to, potentially worsening his symptoms.

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Correct Answer is C

Explanation

A. the client feels vulnerable to stigma: While stigma can prevent clients from reporting suicidal thoughts, this is not the primary reason for initiating a suicide risk assessment.

B. young adults tend to use manipulation: Assuming that young adults manipulate their symptoms is not a valid reason for initiating a suicide risk assessment. This response is inappropriate and can harm the therapeutic relationship.

C. this is a standard assessment: A suicide risk assessment is a standard part of care for clients with depression and thoughts of hopelessness, even if suicidal ideation is not explicitly reported. This ensures comprehensive evaluation and appropriate intervention.

D. the client lives with extended family: The living situation may influence the support system, but it is not the primary reason to initiate a suicide risk assessment.

A. "Are you feeling worse since taking the medication?" B. "How long have you been taking the medication?" C. "What time of day are you taking the medication?" D. "What dosage of medication are you taking?"

Correct Answer is B

Explanation

A. "Are you feeling worse since taking the medication?" This is an important safety question to ask, as it helps to assess whether the client’s condition has worsened since starting the medication. However, it is not the first priority when evaluating the efficacy of a newly prescribed antidepressant.

B. "How long have you been taking the medication?" This is the most important question to ask first because the effectiveness of imipramine, a tricyclic antidepressant, can take several weeks to become apparent. If the client has not been taking the medication for an adequate period, the drug may simply not have had enough time to work yet.

C. "What time of day are you taking the medication?" While the timing of the medication can affect side effects, it is less critical than knowing how long the client has been on the medication when assessing its effectiveness.

D. "What dosage of medication are you taking?" This is an important follow-up question but not the first priority. The duration of treatment is more critical to assess before considering dosage adjustments.

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is providing education via phone to a client who called stating that the newly prescribed imipramine (Tofranil) is not working as depression is still a problem. Which question is most important to ask first?

Correct Answer is B

Explanation

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