While caring for a depressed client, a nurse would evaluate the need for suicide precautions under which circumstance?

The client displays agitation.

The client becomes suddenly cheerful.

The client experiences psychomotor retardation.

The client does not attend group therapy.

Answer and Explanation

The Correct Answer is B

A.   Agitation can be a sign of distress, but sudden cheerfulness may be indicative of a decision to act on suicidal thoughts, as the individual may feel relieved to have made a decision.
B.   Sudden cheerfulness can be a concerning sign, as it may indicate that the client has made a decision to carry out suicidal thoughts.
C.   Psychomotor retardation is a symptom of depression and may not necessarily indicate imminent risk of suicide.
D.   Not attending group therapy may be a sign of withdrawal or isolation, but it does not directly indicate immediate suicidal risk.

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Correct Answer is C

Explanation

A) Incorrect. While discussing various topics is important, providing continuity of care is more crucial in creating a therapeutic environment for clients with paranoia and schizophrenia.

B) Incorrect. Focusing on client strengths rather than weaknesses is generally a more effective approach in mental health care.

C) Correct. Providing continuity of care by assigning the same staff helps build trust and a sense of security for clients, especially those with paranoia and schizophrenia.
D) Incorrect. While it's important to establish boundaries, allowing the client to solely determine them may not always be in their best interest.

A. MAST B. CAGE C. CIWA D. DMSE

Correct Answer is C

Explanation

A. The Michigan Alcohol Screening Test (MAST) is a tool used to screen for alcohol abuse or dependence, but it does not specifically assess withdrawal symptoms.

B. The CAGE questionnaire is used to screen for alcohol abuse, but it does not assess withdrawal symptoms.
C. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) is a validated tool used to assess the severity of alcohol withdrawal symptoms. It includes various criteria such as agitation, tremor, and hallucinations.
D. The Delirium Rating Scale (DMSE) is used to assess the severity of delirium, which can be caused by various factors including alcohol withdrawal, but it is not specific to alcohol withdrawal.

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While caring for a depressed client, a nurse would evaluate the need for suicide precautions under which circumstance?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to run a group for clients diagnosed with paranoia and schizophrenia on an acute care mental health unit. Which of the following actions should the nurse plan to take to create a therapeutic environment?

Correct Answer is C

Explanation

While conducting an admission interview with a client, the nurse suspects the client may be in alcohol withdrawal. Which screening tool can help the nurse identify the severity of withdrawal symptoms?

Correct Answer is C

Explanation

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