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A nurse is assessing a patient diagnosed with major depressive disorder. The patient expresses feelings of hopelessness and states, 'I don't think anything will ever improve.' What is the priority nursing intervention?
- A. Encourage the patient to engage in activities that improve mood.
- B. Assess the patient for suicidal thoughts and ideation.
- C. Provide the patient with positive affirmations and reassurances.
- D. Suggest that the patient take medications to help with their depression.
Correct Answer: B
Rationale: The priority intervention is to assess the patient's risk for suicide, as feelings of hopelessness can indicate a high risk for self-harm. Immediate action is necessary to ensure safety.
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A patient asks the nurse what she should do about her 'cheating' husband. The nurse replies, 'You should divorce him. You deserve better than that.' The nurse used which communication technique?
- A. Giving information
- B. Verbalizing the implied
- C. Giving advice
- D. Agreeing
Correct Answer: C
Rationale: Giving advice tells the client what to do, which is nontherapeutic as it assumes the nurse knows best. Information provides facts, verbalizing the implied clarifies hints, and agreeing aligns with the client, but C overrides client autonomy.
According to the Recent Life Changes Questionnaire, which situation would most necessitate a complete assessment of a person's stress status and coping abilities?
- A. A person who has been assigned more responsibility at work
- B. A parent whose job required relocation to a different city
- C. A person returning to college after an employer ceased operations
- D. A man who recently separated from his wife because of marital problems
Correct Answer: C
Rationale: A person returning to college after losing a job is dealing with two significant stressors simultaneously. Together, these stressors total more life change units than any of the single stressors cited in the other options.
During an interview, a patient attempts to shift the focus from self to the nurse by asking personal questions. The nurse should respond by saying:
- A. Why do you keep asking about me?
- B. Nurses direct the interviews with patients.
- C. Do not ask questions about my personal life.
- D. The time we spend together is to discuss your concerns.
Correct Answer: D
Rationale: Refocusing on the patient, as in Option D, maintains therapeutic boundaries. Options A, B, and C are confrontational or authoritative, risking rapport.
A nurse is assessing a patient diagnosed with bipolar disorder who is experiencing the manic phase. The patient is displaying impulsive behaviors. Which of the following interventions should the nurse implement first?
- A. Provide medication to stabilize the patient's mood.
- B. Set clear limits on impulsive behaviors and prevent harm.
- C. Encourage the patient to express their feelings and engage in social activities.
- D. Allow the patient to make their own decisions and accept the consequences.
Correct Answer: B
Rationale: Setting clear limits on impulsive behaviors is essential to prevent harm and ensure the patient's safety during the manic phase.
Anthony is a 40-year-old patient who lost his job recently and wishes that he was back home living with his parents. Anthony has been noted to do things he used to do when he was a child. Anthony is going through a period of regression. Regression is best defined as:
- A. A retreat to a less stressful time in ones life.
- B. An immature response technique.
- C. An assertive response.
- D. A therapeutic mechanism.
Correct Answer: A
Rationale: During a stressful event, people may revert back to a time that was less stressful.