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A client at the mental health center reports difficulty concentrating at work, feeling very tired during the day, and sleeping 4 to 5 hours at night. To further assess for depression, which question is most important for the nurse to ask?
- A. Have you experienced recent stresses?
- B. What foods do you like to eat?
- C. Do you often feel sad?
- D. Have you experienced sleep changes?
Correct Answer: C
Rationale: Inquiring whether the client often feels sad directly addresses the emotional component of depression, critical for a comprehensive assessment.
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A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit's day room. Which action should the nurse implement first?
- A. Sit in the chair next to the client.
- B. Listen to what the client is saying.
- C. Escort the client to his room.
- D. Administer a PRN sedative.
Correct Answer: B
Rationale: Listening to what the client is saying is crucial to understand the content and nature of the auditory hallucinations, guiding further interventions.
A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the nurse implement first?
- A. Show the client the unit.
- B. Explain the nurse's role to the client.
- C. Read the client his/her rights.
- D. Offer medication to the client.
Correct Answer: B
Rationale: Explaining the nurse's role helps establish trust and provides the client with information about who is present and their purpose, facilitating initial communication.
Which interventions should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)
- A. Reinforce statements regarding a will to live and realistic plans for the future.
- B. Discuss the client's suicide plan.
- C. Limit time allowed to play video games.
- D. Encourage the client to discuss thoughts and feelings about wanting to die.
- E. Restrict visitors to family members only.
Correct Answer: A,B,D
Rationale: Reinforcing a will to live, discussing suicide plans, and encouraging expression of suicidal thoughts promote hope, assess risk, and ensure safety.
A client with opioid dependence makes a statement to the nurse about desiring to lead a healthier lifestyle by making changes in the next 2 weeks. How should the nurse respond?
- A. Support the client to list small behavioral changes needed.
- B. Explain the specific skills needed to prevent a relapse.
- C. Provide teaching on the symptoms of substance use dependence.
- D. Advise the client to reschedule until committing to recovery.
Correct Answer: A
Rationale: Supporting the client to list small behavioral changes is a person-centered approach that promotes achievable progress toward a healthier lifestyle.
Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?
- A. Determine the client's reason for attempting suicide.
- B. Obtain the client's serum hydrocodone/acetaminophen level.
- C. Encourage the client to increase fluid intake.
- D. Observe the client for further narcotic effects.
Correct Answer: A
Rationale: Determining the client's reason for attempting suicide is the highest priority to understand underlying issues and plan appropriate interventions to prevent recurrence.