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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.
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An adolescent who is exhibiting a depressed affect receives a prescription for an antidepressant drug. While the client is taking the antidepressant, which comparison of the client's behavior before and after taking the drug is most important for the nurse to obtain?
- A. Level of activity.
- B. The interactions with others.
- C. The emotional quality of attitude.
- D. Appetite.
Correct Answer: C
Rationale: The emotional quality of attitude reflects the client's internal state and is a key indicator of the antidepressant's impact on their depressive symptoms, making it the most critical aspect to assess.
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.
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.
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.
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.