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A nurse is making a home visit for a 16-year-old adolescent who attempted suicide. Which of the following behaviors should alert the nurse that the adolescent still has suicidal intent?
- A. Telling his parents that he doesn't want to talk about the suicide attempt.
- B. Stating that he wants to be with his peers more than with his parents.
- C. Preferring to eat his meals while watching TV.
- D. Planning to give his CD collection to his girlfriend.
Correct Answer: D
Rationale: The correct answer is D: Planning to give his CD collection to his girlfriend. This behavior indicates the adolescent is making future plans involving giving away possessions, which could be a sign of continued suicidal ideation. Giving away prized possessions is often seen as a way of saying goodbye or preparing for death. Choices A, B, and C do not necessarily indicate ongoing suicidal intent. A may suggest avoidance, B may indicate a desire for peer support, and C may be a personal preference. Therefore, D is the most concerning behavior that warrants immediate attention.
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A nurse is caring for a client who is hospitalized and says to the nurse, "My partner called and told me my boss hired someone to take my place." Which of the following responses should the nurse make?
- A. "You should call your boss and ask if you can have your job back."
- B. "I don't understand why your partner would upset you with news like that."
- C. "There really isn't much you can do about that until you are discharged."
- D. "You must feel very concerned and disappointed by that information."
Correct Answer: D
Rationale: Acknowledging the client’s emotions promotes therapeutic communication.
A nurse is caring for a client who has major depressive disorder (MDD). Which of the following findings should the nurse expect?
- A. Significant change in weight
- B. Hyperexcitability
- C. Exaggerated response to stimuli
- D. Attention-seeking behavior
Correct Answer: A
Rationale: The correct answer is A: Significant change in weight. In major depressive disorder (MDD), clients commonly experience appetite changes, leading to weight gain or weight loss. This is due to disturbances in their eating patterns. Weight changes can be a result of decreased interest in food or emotional eating. This is a key symptom to monitor in clients with MDD. Hyperexcitability (B), exaggerated response to stimuli (C), and attention-seeking behavior (D) are not typical findings in clients with MDD. Hyperexcitability and exaggerated response to stimuli are more often associated with conditions like anxiety disorders, while attention-seeking behavior is more commonly seen in personality disorders.
Where should a nurse assign a client experiencing manic behavior?
- A. Semi-private room across from the day room
- B. Private room in a quiet location
- C. Semi-private room across from the snack area
- D. Shared room near the nursing station
Correct Answer: B
Rationale: The correct answer is B: Private room in a quiet location. This choice is appropriate because a client experiencing manic behavior requires a calm and quiet environment to minimize stimulation and help reduce agitation. Placing the client in a private room can provide the necessary space for the client to calm down and prevent potential triggers for further manic episodes.
Other choices are incorrect:
A: A semi-private room across from the day room may expose the client to increased noise and activity, which can exacerbate manic behavior.
C: A semi-private room across from the snack area may lead to distractions and potential interactions that can escalate the manic behavior.
D: A shared room near the nursing station may not offer the privacy and quiet environment needed for a client experiencing manic behavior to stabilize.
A nurse in a psychiatric unit is caring for several clients. Which of the following clients should the nurse recommend for group therapy?
- A. A client who has been taking amitriptyline for 3 months for depression.
- B. A client exhibiting psychotic behavior.
- C. A client admitted 12 hours ago for acute mania.
- D. A client who is experiencing alcohol intoxication.
Correct Answer: A
Rationale: Clients who have stabilized with medication are appropriate for group therapy.
A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After showing the client to his room, which of the following nursing actions is most therapeutic at this time?
- A. Suggest that the client rest in bed.
- B. Remain with the client for a while.
- C. Medicate the client with a sedative.
- D. Have the client join a therapy group.
Correct Answer: B
Rationale: The correct answer is B: Remain with the client for a while. This is the most therapeutic action as it provides immediate support and reassurance to the client experiencing panic-level anxiety. Remaining with the client allows the nurse to offer a calming presence, demonstrate empathy, and help the client feel safe and supported. It also helps to establish a therapeutic relationship and can assist in de-escalating the client's anxiety.
A: Suggesting the client rest in bed may not address the client's immediate emotional needs and could be perceived as dismissive.
C: Medicating the client with a sedative should only be done after a thorough assessment by a healthcare provider and is not the initial therapeutic action.
D: Having the client join a therapy group may be overwhelming for someone experiencing panic-level anxiety and may not be the most appropriate intervention at this time.