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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?
- A. Allow the client to rest and sleep.
- B. Begin planning for the client's discharge.
- C. Encourage verbalization of feelings.
- D. Ensure the client attends groups addressing coping skills for dealing with depression.
Correct Answer: A
Rationale: Allowing the client to rest and sleep is a priority, as sleep deprivation can exacerbate depression symptoms, addressing immediate physical needs.
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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.
During a one-to-one session with the nurse, a female client admitted for chronic depression and attempted suicide discloses experiences of sexual promiscuity and prostitution. When the nurse asks the client if she was ever sexually abused as a child, the client says, “I don't remember, but my mother ran my father off when I was five.†The nurse should recognize that the client may be using which defense mechanism?
- A. Regression.
- B. Projection.
- C. Denial.
- D. Repression.
Correct Answer: D
Rationale: Repression involves unconsciously blocking out memories, and the client's inability to recall potential abuse suggests this defense mechanism.
A client with post-traumatic stress disorder (PTSD) is experiencing a dissociative disorder episode. The situation quickly escalates, and the client becomes physically aggressive. Which intervention should the nurse implement first?
- A. Request a team member to assist with seclusion and restraint.
- B. Administer lorazepam 1.5 mg intramuscularly twice daily as needed.
- C. Confirm the client's identity and orientation to time and place.
- D. Inspect the area for objects that can be used in a dangerous manner.
- E. None.
- F. None.
Correct Answer: D
Rationale: Inspecting the area for dangerous objects is the first priority to ensure safety during the client's aggressive behavior.
The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the client's history should the nurse further explore?
- A. Family history of dementia.
- B. Witness to an accident.
- C. Alcohol use.
- D. Inadequate diversional activity.
Correct Answer: C
Rationale: Alcohol use can contribute to sleep disturbances, including nightmares, making it a critical factor to explore in relation to the client's symptoms.
A male client, assessed in the emergency department (ED), has a strong odor of alcohol on his breath. The client denies thoughts of harm to self or others, and the healthcare provider discharges the client. As the client begins to leave, the nurse overhears the client mumble, “Now I'm going to shoot myself.†Which intervention should the nurse implement?
- A. Inquire about the client's support system.
- B. Ask the client to repeat his comment.
- C. Stop the client from leaving the ED.
- D. Record the statement in the client's chart.
Correct Answer: C
Rationale: Stopping the client from leaving the ED is the priority to ensure safety and prevent potential self-harm based on the overheard statement.