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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.
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A male client with schizophrenia continues to talk to others on the mental health unit using tangential speech. What intervention should the nurse implement?
- A. Tell the client to discuss his ideas with others when his thoughts are more clear.
- B. Teach the client to slow down and focus on the topic by listening to his words.
- C. Ask the client to repeat his comments.
- D. Confront the client when he talks rapidly.
Correct Answer: B
Rationale: Teaching the client to slow down and focus on the topic by listening to his words is a therapeutic intervention to address tangential speech and improve communication.
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 who is an alcoholic receives a prescription for disulfiram 500 mg PO daily. Which instruction should the nurse provide to this client?
- A. Take the medication each morning beginning 48 hours after your last drink of alcohol.
- B. Take the medication with at least 8 ounces of water and limit alcohol consumption while taking this medication.
- C. Take the medication at bedtime and avoid consuming any more than one ounce of alcohol daily.
- D. Begin taking the medication immediately and take it daily, regardless of whether or not you drink alcohol.
Correct Answer: A
Rationale: Disulfiram should be taken each morning, starting 48 hours after the last drink to prevent a severe reaction, establishing a clear association between the medication and alcohol avoidance.
When a male client is asked about his reason for coming to the mental health clinic, he replies, “It all started because I work in a hostile work environment. My boss would not let me go to a religious service, so I went to human resources, and they didn't want to do anything. It has been a really difficult time for me.†Which response should the nurse provide?
- A. Why do you think you have a hostile work environment?
- B. Have you considered resigning from your position?
- C. Have the feelings associated with these events brought you to the clinic?
- D. How have you responded to those in your work environment about these events?
Correct Answer: C
Rationale: This response acknowledges the client's feelings and experiences, allowing for further exploration of the issues that brought him to the clinic, fostering therapeutic communication.
During a high school substance abuse class, a student tells the group, “I know that marijuana is not addicting, so why shouldn't I use it? Which response is best for the nurse to provide?
- A. Marijuana is a highly addictive substance.
- B. Altering one's ability to think clearly places self and others at risk.
- C. Healthcare providers sometimes prescribe marijuana to control nausea.
- D. Drug use has moral implications that should be discussed with parents.
Correct Answer: B
Rationale: This response highlights the immediate risk of impaired thinking, emphasizing potential harm to self and others from marijuana use.