Nokea
A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (Select all that apply.)
- A. Grooming
- B. Long-term memory
- C. Support systems
- D. Affect
- E. Presence of pain
Correct Answer: A, B, D
Rationale: The correct choices for the nurse to include in the MSE for a client with dementia are A, B, and D. Grooming is important to assess the client's self-care ability, which can be impacted by dementia. Long-term memory is essential in evaluating cognitive decline typically seen in dementia. Affect assessment helps determine emotional responses and can indicate changes in mood associated with dementia. Support systems (choice C) are not typically part of the MSE but are relevant for treatment planning. Presence of pain (choice E) is important but not a traditional component of a mental status examination.
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A nurse in an emergency department is performing an assessment on a client who reports being sexually assaulted. Which of the following actions should the nurse take first?
- A. Ask the client for permission to take photographs.
- B. Document the client's verbatim statements.
- C. Provide community sexual assault support contacts.
- D. Determine any physical signs of injury.
Correct Answer: D
Rationale: The correct answer is D: Determine any physical signs of injury. This should be the first action taken by the nurse in this situation because assessing for physical signs of injury is crucial for ensuring the client's immediate safety and well-being. By assessing for physical injuries, the nurse can prioritize medical treatment if needed and gather important forensic evidence. This initial assessment also helps in determining the urgency of the situation and guides the next steps in providing appropriate care and support.
Choices A, B, and C are incorrect as they are not the priority in this situation. Asking for permission to take photographs, documenting verbatim statements, and providing community sexual assault support contacts are important actions but should come after ensuring the client's immediate physical well-being is addressed. It is essential to focus on the client's physical safety and health first before moving on to other aspects of care and support.
A nurse in an emergency department is assessing a client who has traumatic injuries following an assault. The client sits quietly and calmly in the examination room and states, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions?
- A. Denial
- B. Displacement
- C. Projection
- D. Undoing
Correct Answer: A
Rationale: The correct answer is A: Denial. The client's calm demeanor and statement of "I'm fine" despite having traumatic injuries indicate a defense mechanism of denial, where the client is refusing to acknowledge the severity of their situation. Denial helps the individual cope with overwhelming emotions or stress by avoiding the reality of the situation. Displacement involves redirecting emotions to a less threatening target, projection involves attributing one's thoughts or feelings to others, and undoing involves engaging in behaviors to counteract negative thoughts or actions. In this scenario, denial is the most appropriate reaction based on the client's behavior.
A nurse on a crisis hotline is speaking to a client who says, "I just took an entire bottle of amitriptyline." Which of the following responses should the nurse make?
- A. "I'm glad you called, and I want to send an ambulance to help you."
- B. "You must have been feeling pretty depressed to do that."
- C. "Do you know how many pills were in the bottle?"
- D. "Were you trying to kill yourself by taking an overdose?"
Correct Answer: A
Rationale: The correct response is A: "I'm glad you called, and I want to send an ambulance to help you." This answer demonstrates immediate concern for the client's well-being and prioritizes getting them the necessary medical help. It acknowledges the seriousness of the situation and the potential danger of taking an entire bottle of medication. Sending an ambulance ensures that the client receives prompt medical attention, which is crucial in cases of overdose.
Incorrect responses:
B: "You must have been feeling pretty depressed to do that." - This response focuses on the client's emotional state rather than addressing the immediate need for medical assistance.
C: "Do you know how many pills were in the bottle?" - This question does not prioritize the urgency of the situation and does not address the immediate need for medical help.
D: "Were you trying to kill yourself by taking an overdose?" - This response may come off as accusatory and could potentially escalate the situation. It is important to prioritize the client's safety and well-being
A school nurse is speaking to the mother of a 16-year-old male adolescent. The mother has concerns about her son. Which of the following statements by the mother should indicate to the nurse that the adolescent is at risk for suicide?
- A. "His favorite teacher committed suicide a few weeks ago."
- B. "He has slept 9 hours each night for the past 2 years."
- C. "He is very religious and attends services twice a week."
- D. "He spends much of his time with his two school friends."
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The statement "His favorite teacher committed suicide a few weeks ago" indicates exposure to suicide, which is a risk factor for suicidal behavior. This experience can trigger feelings of hopelessness and increase the risk of suicide in adolescents. The mother's concern in this context is valid and should be taken seriously.
Summary:
B: Sleeping 9 hours each night for the past 2 years is not a direct indicator of suicide risk. While changes in sleep patterns can be a sign of depression, it is not as specific as exposure to suicide.
C: Being religious and attending services twice a week is not necessarily an indicator of suicide risk. Religious beliefs can provide comfort and support.
D: Spending time with friends is generally a positive sign of social connectedness, which can be protective against suicide.
A client commits suicide in an acute mental health facility. Which of the following is the priority intervention for staff following this incident?
- A. Provide professional counseling for staff members.
- B. Change policies for staff observation of clients who are suicidal.
- C. Identify cues in the client's behavior that might have warned them that he was contemplating suicide.
- D. Give the family an opportunity to talk about their feelings.
Correct Answer: C
Rationale: The correct answer is C: Identify cues in the client's behavior that might have warned them that he was contemplating suicide. This is the priority intervention because understanding the warning signs can help prevent future suicides by recognizing and addressing high-risk behaviors. Providing counseling (A) is important but not the immediate priority. Changing policies (B) may be necessary in the long term but does not address the current situation. Giving the family an opportunity to talk (D) is important for support but does not directly address staff intervention.