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A client who is experiencing a severe level of anxiety reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?
- A. Help the client identify thoughts that may be triggers.
- B. Explore past behaviors that have provided relief.
- C. Attempt to distract to another focus or activity.
- D. Speak calmly to the client stating assurance of safety.
Correct Answer: D
Rationale: Speaking calmly and providing assurance of safety is the first step in managing severe anxiety, helping to stabilize the client.
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A young adult male client is admitted to the psychiatric unit because of a recent suicide attempt. His wife filed for divorce six months ago, he lost his job three months ago, and his best friend moved to another city two weeks ago. Which intervention should the nurse include in this client's plan of care?
- A. Avoid discussing subjects that upset the client.
- B. Encourage activities that allow the client to exert control over his environment.
- C. Allow the client time alone to sort out his feelings.
- D. Encourage the client to interact with persons who are recovering from depression.
Correct Answer: B
Rationale: Encouraging activities that allow the client to exert control over his environment helps empower the client and regain a sense of agency, which is critical for improving mental health post-suicide attempt.
Which individual should the nurse consider at the highest risk for suicide?
- 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: B
Rationale: Adolescents experiencing major life changes, such as parental divorce, are at an elevated risk for suicide due to emotional and social stressors.
While visiting the community mental health center, a client with a diagnosis of major depressive disorder asks the nurse if what is shared with the staff will be shared with family members. How should the nurse respond to this client?
- A. Provide the client with a written hospital policy regarding privacy of information laws.
- B. Tell the client that confidentiality will be maintained, except when one's safety is threatened.
- C. Nod in the affirmative, but make no verbal commitment to the client.
- D. Assure the client that information provided will be shared with the staff only.
Correct Answer: B
Rationale: This response provides accurate information about confidentiality while acknowledging exceptions when safety is at risk, addressing the client's concern clearly.
While assessing a client with the diagnosis of schizophrenia who wears dentures, the nurse observes that the client's tongue is “wormingâ€. The client also demonstrates an inability to articulate words clearly. Which additional assessment is most important for the nurse to obtain?
- A. Usual level of activity and average sleep pattern.
- B. Blood pressure when sitting and standing.
- C. Dentures to determine if they are poorly fitted.
- D. Body weight over the past three months.
Correct Answer: C
Rationale: Assessing the fit of dentures is crucial, as poorly fitted dentures could contribute to speech difficulties and tongue abnormalities observed.
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. Disturbed sensory perception.
- B. Compromised family coping.
- C. Ineffective sexual patterns.
- D. Impaired environmental interpretation.
Correct Answer: A
Rationale: The client's statements suggest a distorted perception of reality, indicating disturbed sensory perception, which addresses potential psychosis and immediate safety concerns.