The nurse working with a teen, who has a history of being moody and withdrawn, will make the establishment of a therapeutic alliance a priority because:

the client should express feelings and not keep them inside.

therapeutic activities provide an outlet for tension.

acceptance and trust convey feelings of security to the client.

focusing on the behaviors of an individual increases the person's self-esteem

Answer and Explanation

The Correct Answer is C

C. Acceptance and trust create a sense of safety and security for the client within the therapeutic relationship. When the client feels accepted and valued by the nurse, they are more likely to feel comfortable opening up and engaging in the therapeutic process.
A. Establishing a therapeutic alliance provides a safe and supportive environment for the client to express their feelings without fear of judgment or rejection. However, therapeutic alliance goes beyond this.
B. Therapeutic activities can indeed provide an outlet for tension and stress but the establishment of a therapeutic alliance goes beyond engaging in specific activities.
D. Focusing on positive behaviors and strengths can contribute to building self-esteem. However, the establishment of a therapeutic alliance involves more than just focusing on behaviors.

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Correct Answer is D

Explanation

D. Suicide precautions involve implementing safety measures and close monitoring to prevent the client from engaging in self-harm or suicide attempts. This may include continuous observation, removal of

potentially harmful objects or substances from the client's environment, and close supervision by staff members trained in suicide prevention.
A. Assessing for past suicide attempts can provide valuable information about the severity of the client's suicidal ideation, their previous experiences with suicidal behavior, and any patterns or triggers associated with suicidal crises. However, it is not a priority.
B. Assessing for a specific suicide plan allows the treatment team to evaluate the level of risk and urgency of intervention required to keep the client safe. However, with or without a plan, safety should be prioritized.
C. identifying coping mechanisms is important for overall mental health and well-being. However, it is not the priority intervention when a client reports current suicidal ideation.

A. Insert a nasogastric tube B. Monitor airway and vital signs C. Insert an indwelling urinary catheter or monitor output D. Anticipate and treat hyperpyrexia with cooling measures

Correct Answer is B

Explanation

B. Naloxone administration can rapidly reverse the effects of opioids, potentially leading to the rapid onset of opioid withdrawal symptoms, which may include respiratory depression. Therefore, close monitoring of the client's airway, respiratory rate, oxygen saturation, blood pressure, and heart rate is critical to ensure their safety and stability.
A. Assessing and managing the client's gastrointestinal status may be necessary depending on the clinical situation but it is not the most urgent concern immediately following naloxone administration.
C. Assessing urinary output and ensuring adequate fluid balance is important. However, it is not the highest priority immediately after naloxone administration.
D. Hyperpyrexia, or extremely high fever, is not a common immediate concern following naloxone administration.

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The nurse working with a teen, who has a history of being moody and withdrawn, will make the establishment of a therapeutic alliance a priority because:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client notifies a treatment team member of current suicidal ideation. Which nursing intervention would take priority?

Correct Answer is D

Explanation

The nurse is caring for a client who just received naloxone. Which nursing intervention is highest priority?

Correct Answer is B

Explanation

A 7-year-old with Attention Deficit-Hyperactivity Disorder (ADHD) evaluated at the mental health clinic is exhibiting hyperactivity and distractibility. The nurse should monitor for which desired outcome?

The intervention appropriate for a client who has been manipulating others and has a diagnosis of antisocial personality disorder is to:

A client plans to go to an acupuncturist for complementary treatment of alcoholism. He asks the nurse to explain how acupuncture works. The most accurate response would be "Acupuncture is a traditional Chinese medical treatment. The Chinese believe that:

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The nurse is administering furosemide 40 mg PO to a client who has peripheral edema. Which method would the nurse use to best evaluate the client's response to this medication?

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The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. Which screening tool should the nurse use to further evaluate this possibility?

The nurse is assessing a newly admitted client whose chief complaint is "coughing up blood" and whose recent history includes a productive cough and night sweats. What is the nurse's priority intervention?