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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.
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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.
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.
The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?
- A. The voices you are hearing are not real.
- B. Let's talk about the next time this happens.
- C. You need to be calm and focus on something else.
- D. You appear to be speaking with someone.
- E. None.
- F. None.
Correct Answer: D
Rationale: Acknowledging that the client appears to be speaking with someone validates their experience without confirming the reality of the voices, encouraging further communication.
A client with generalized anxiety disorder (GAD) receives a new prescription for lorazepam. Which statement provided by the client requires additional instruction by the nurse?
- A. Use relaxation techniques to reduce excessive anxiety.
- B. Avoid alcohol and other sedatives while taking the medication.
- C. Move slowly from a sitting position to a standing position.
- D. Stop taking the medication if the intended effect is not immediate.
Correct Answer: D
Rationale: Stopping the medication if the effect is not immediate is incorrect, as lorazepam may take time to achieve full effect, and abrupt discontinuation can cause withdrawal.
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.