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?

The voices you are hearing are not real

Let’s talk about the next time this happens

You need to be calm and focus on something else

You appear to be speaking with someone

None

Answer and Explanation

The Correct Answer is D

A. Telling the client that the voices they are hearing are not real may invalidate their experience and could increase their distress or resistance to the nurse's intervention.
B. While discussing strategies for the next occurrence might be helpful, it does not address the immediate situation or acknowledge the client's current experience.
C. Asking the client to focus on something else may be perceived as dismissive and may not effectively engage them in conversation or provide support.
D. Acknowledging that the client appears to be speaking with someone validates their experience without confirming the reality of the voices. This comment encourages the client to express themselves and provides an opening for further communication, allowing the nurse to assess the situation more effectively.

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Correct Answer is D

Explanation

A. Regression involves reverting to an earlier stage of development in response to stress, which is not evident in the client's response.
B. Projection involves attributing one's thoughts or feelings to another person, which is not evident in the client's response.
C. Denial involves refusing to acknowledge the existence of something unpleasant, which is not evident in the client's response.
D. Repression involves unconsciously blocking out memories or feelings, and the client's statement of not remembering past sexual abuse may indicate the use of repression as a defense mechanism.

A. A nurse who works in a pediatric emergency department. B. An adolescent male whose parents recently divorced. C. A retired older male whose significant other has passed away. D. A single working mother with three preschool-aged children.

Correct Answer is B

Explanation

A. While working in a pediatric emergency department can be stressful, the information provided does not suggest an increased risk for suicide in this scenario.
B. Adolescents experiencing major life changes, such as parental divorce, are at an elevated risk for suicide.
C. While the loss of a significant other can contribute to increased suicide risk in older adults, the information provided does not indicate an immediate concern.
D. While being a single working mother with young children is challenging, the information provided does not suggest an increased risk for suicide in this scenario.

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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?

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Correct Answer is D

Explanation

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

Correct Answer is B

Explanation

A homeless female client who reports feeling sad and depressed tells the mental health nurse that in the past two days, the client has only had four hours of sleep. Which action is most important for the nurse to implement within the first 24 hours after treatment is initiated?

When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client’s record should the nurse review?

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A client with chronic alcohol dependency is admitted due to a recent relapse. Which findings should the nurse expect this client to exhibit? (Select all that apply)

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After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping both feet while pacing the hallway. Which action should the nurse take?