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A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide. Which of the following findings should the nurse identify as a risk factor for suicide?
- A. Currently married.
- B. Access to guns in the home.
- C. Terminal liver cancer.
- D. Alcohol use disorder.
Correct Answer: B,C,D
Rationale: Access to guns in the home, terminal liver cancer, and alcohol use disorder are significant risk factors for suicide. Guns increase lethality, terminal illness causes distress, and alcohol impairs judgment and increases impulsivity, all elevating suicide risk.
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A nurse is caring for a newly admitted client who has obsessive-compulsive disorder. Which of the following actions should the nurse take first?
- A. Discuss the benefits of relaxation exercises with the client.
- B. Explain the use of response prevention to the client.
- C. Administer an antianxiety medication.
- D. Calculate the client's score on the Hamilton Rating Scale for Anxiety.
Correct Answer: D
Rationale: Calculating the Hamilton Rating Scale for Anxiety provides an initial assessment of the client's anxiety severity, guiding further interventions. This baseline data collection is the priority upon admission to tailor subsequent care.
A nurse is preparing to administer sertraline 50 mg PO once daily to a client who has depressive disorder. Available is sertraline oral solution 20 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 2.5
Rationale: Step 1: (50 mg ÷ 20 mg/mL) × 1 mL = 2.5 mL. The nurse should administer 2.5 mL to deliver the prescribed 50 mg dose, calculated based on the concentration of the available solution.
A nurse in a substance use disorder clinic is explaining the alcohol recovery process to a client's family. Which of the following should the nurse identify as the first step toward successful recovery from alcohol use disorder?
- A. Form a close support network.
- B. Acknowledge an inability to control drinking.
- C. Incorporate a form of spirituality into daily life.
- D. Agree to a prescription for an alcohol use deterrent.
Correct Answer: B
Rationale: Acknowledging an inability to control drinking is crucial as it represents acceptance of the problem. Without this self-awareness, the individual is unlikely to seek or benefit from treatment options. This step is foundational, preceding the use of support networks, spirituality, or medication.
A nurse is participating in a community program about eating disorders. Which of the following information about bulimia nervosa should the nurse include in the presentation?
- A. People who have bulimia nervosa are at risk for developing diabetes mellitus.
- B. Bulimia nervosa is difficult to notice because a person might be of average or ideal body weight.
- C. People who have bulimia nervosa eat an average amount of food on a daily basis.
- D. As long as a person is not vomiting after eating, they do not have bulimia nervosa.
Correct Answer: B
Rationale: Individuals with bulimia nervosa often maintain an average or ideal body weight, making the disorder less visible. This highlights a key characteristic for community education.
A nurse is caring for a client who has an opioid use disorder. The nurse should anticipate that the provider will prescribe which of the following medications for treatment?
- A. Phenobarbital.
- B. Diazepam.
- C. Chlordiazepoxide.
- D. Buprenorphine.
Correct Answer: D
Rationale: Buprenorphine is a partial opioid agonist used in medication-assisted treatment for opioid use disorder, helping to reduce cravings and withdrawal symptoms. It’s specifically indicated for this condition.