The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Alert the assigned staff to closely monitor client and intervene as needed to reduce risk of selfmutilation.

Provide the client time alone in the client's room to reduce external stimulation and promote relaxation.

Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed.

Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm.

Answer and Explanation

The Correct Answer is A

A. The client's increased body tension and pacing indicate escalating distress and potential risk for self-harm. Alerting staff to closely monitor the client and intervene as needed is crucial to ensure the client's safety.
B. Providing time alone in the client's room may be appropriate in some situations but may not address the immediate risk of self-mutilation if the client is experiencing escalating distress. C. Giving firm, consistent expectations about self-mutilating behaviors is important for establishing boundaries, but it may not be sufficient to address the immediate risk of self-harm without additional monitoring and intervention.
D. Completing a thorough room search is important for safety but may not address the immediate risk of self-harm if the client is already exhibiting signs of distress and pacing in the hallway.

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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. A The client should plan to participate in group or individual therapy while at college. B. The client's serum lithium levels should be routinely evaluated. C. The client should be aware of the signs and symptoms of his illness. D. Despite the illness, the client should be able to live away from home.

Correct Answer is B

Explanation

A. While participation in therapy may be beneficial, the most important consideration with lithium therapy is monitoring serum levels to ensure therapeutic efficacy and avoid toxicity.
B. Lithium therapy requires regular monitoring of serum levels to maintain therapeutic efficacy and prevent toxicity, especially during times of transition or stress such as starting college
C. While it is important for the client to be aware of the signs and symptoms of his illness, routine monitoring of serum lithium levels is more crucial for maintaining stability while living away from home.
D. While independence is a positive goal, the focus in this scenario should be on ensuring the client's safety and stability through appropriate monitoring of lithium levels.

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The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Nursing Test Bank

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

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?

Correct Answer is B

Explanation

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

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

A young female client is admitted to the emergency room because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record as the client's chief complaint?

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