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A nurse in an acute care mental health facility is assessing a client who has bipolar disorder. The nurse recognizes that which of the following findings indicates the client is at risk for suicide?
- A. The client has demonstrated increased impulsive behaviors in the past few weeks.
- B. The client states she wants to go home to be with her children and partner.
- C. The client identifies with problems expressed by other clients.
- D. The client has begun playing basketball with several other clients during the past month.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Increased impulsive behaviors in bipolar disorder may indicate heightened risk for suicide due to poor impulse control.
2. Impulsivity is a known risk factor for suicidal behavior in individuals with bipolar disorder.
3. Impulsive actions can lead to reckless behaviors that may result in self-harm or suicide.
4. Monitoring and addressing impulsivity is crucial in assessing suicide risk in clients with bipolar disorder.
Incorrect Choices:
B. Wanting to be with family is a protective factor, reducing suicide risk.
C. Identifying with others' problems may indicate empathy but does not directly suggest suicide risk.
D. Engaging in group activities like basketball is a positive coping strategy and does not inherently indicate suicide risk.
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A nurse is caring for an adolescent client who has a new diagnosis of schizophrenia. The client's parents are tearful and express feelings of guilt. Which of the following is an appropriate statement by the nurse?
- A. Your provider has explained the causes of schizophrenia. Why do you feel guilty about your daughter's diagnosis?
- B. You said that you feel guilty about your daughter's diagnosis. Let's talk about what is causing you to feel this way.
- C. You should not feel guilty about your daughter's diagnosis. Schizophrenia is unpreventable.
- D. I'm sure your daughter's diagnosis is very difficult to deal with, but everything will be all right once she receives the proper treatment.
Correct Answer: B
Rationale: Rationale: Choice B is the correct answer because it acknowledges the parents' feelings of guilt and opens the door for communication. By reflecting the parents' emotions and offering to discuss the underlying reasons, the nurse is validating their feelings and promoting therapeutic communication. This approach fosters trust and allows the parents to express their concerns, ultimately leading to better understanding and support.
Incorrect Choices:
A: This response may come off as confrontational by questioning the parents' feelings of guilt, potentially making them defensive and hindering open communication.
C: While it is true that schizophrenia is not preventable, simply stating this does not address the parents' emotional needs or provide support.
D: This response minimizes the parents' feelings and offers false reassurance without addressing the root cause of their guilt.
A nurse is providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse?
- A. A child whose parents answer questions for the child
- B. A child who has frequent visitors
- C. A child who has a BMI indicating obesity
- D. A child who uses the call light frequently
Correct Answer: A
Rationale: The correct answer is A. When parents answer questions for the child, it may indicate a lack of autonomy or control over their own care, suggesting potential abuse or neglect. This behavior can be a red flag for the nurse to further assess the child's situation. Choices B, C, and D do not necessarily indicate abuse. Frequent visitors could be a sign of social support, obesity may be due to various factors, and using the call light frequently may indicate medical needs rather than abuse. It is essential for the nurse to explore further if a child's autonomy is being compromised.
A nurse is planning care for a client who has hyperthyroidism and is receiving radioactive iodine (radioiodine). Which of the following statements by the nurse regarding special precautions is appropriate?
- A. You will need to use a bathroom separate from other household members.
- B. You will need to remain at the hospital for the entire time the radioiodine is radioactive.
- C. A low fiber diet will be necessary.
- D. Additional Immunizations will be needed for full protection.
Correct Answer: A
Rationale: Rationale: Choice A is correct because radioiodine is excreted through bodily fluids including urine. Using a separate bathroom prevents exposure to others. Choice B is incorrect as hospitalization isn't always required. Choice C is irrelevant to radioiodine therapy. Choice D is incorrect as immunizations are not directly related to radioiodine precautions.
A nurse is caring for a client who has been diagnosed with end-stage liver cancer. The nurse recognizes that which of the following responses is an indication that the client is in the denial phase of the grief process?
- A. I can't believe the doctor graduated from medical school. He doesn't know a thing about treating cancer!
- B. Even though I am not hurting right now, I don't feel like I have the energy to get out of bed.
- C. The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication.
- D. The doctor has been so good to me. I know he has tried everything he can. It's just my time.
Correct Answer: C
Rationale: The correct answer is C. In this response, the client is demonstrating denial by refusing to accept the doctor's prognosis of having only a few months to live. This indicates an inability to acknowledge the severity of the situation, a common characteristic of the denial phase in the grief process. The client's belief that the doctor is exaggerating shows a defense mechanism to cope with the overwhelming truth. Options A, B, and D do not exemplify denial. Option A shows anger, Option B indicates depression, and Option D reflects acceptance and resignation, which are not characteristics of denial in the grief process.
A client has made the decision to leave her alcoholic husband and reports feeling very depressed. Which of the following is a non-therapeutic statement by the nurse that demonstrates sympathy?
- A. You are feeling very depressed. I felt the same way when I decided to leave my husband.
- B. I can understand you are feeling depressed. It was a difficult decision. I'll sit with you.
- C. You seem depressed. It was a difficult decision to make. Would you like to talk about it?
- D. I know this is a difficult time for you. Would you like medication for anxiety?
Correct Answer: A
Rationale: The correct answer is A because the nurse is sharing her personal experience, which is not therapeutic as it shifts the focus from the client to the nurse's own experience. This can make the client feel unheard and invalidated. Choice B demonstrates empathy and offers support by acknowledging the client's feelings and offering to sit with them. Choice C also shows empathy and provides an opportunity for the client to talk. Choice D is non-therapeutic as it jumps to suggesting medication without exploring the client's emotions or needs.