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A nurse is planning a unit orientation for a newly admitted client who has severe depression. Which of the following should be the nurse's approach?
- A. Sit with the client and offer simple, direct information.
- B. Have the client attend group therapy immediately.
- C. Explain the unit policies to the client and answer any questions he might have.
- D. Take the client on a tour of the unit and introduce him to all the staff members on duty.
Correct Answer: A
Rationale: Clients with severe depression may have difficulty processing large amounts of information, so simple, direct communication is best.
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A nurse is assessing a parent who lost a 12-year-old child in a car crash 2 years ago. Which of the following findings indicates the client is exhibiting manifestations of prolonged grieving?
- A. Leaves the child's room exactly as it was before the loss
- B. Volunteers at a local children's hospital
- C. Talks about the child in the past tense
- D. Visits the child's grave every week after worship services
Correct Answer: A
Rationale: In prolonged grief, individuals may struggle to move forward and avoid changing their environment.
A nurse is caring for an adolescent who has a history of violent behavior and has asked the nurse to keep confidential information about the desire to kill several classmates and a school teacher. Which of the following responses by the nurse is appropriate to give?
- A. "Because you are a minor, I have to share any information that I feel is important with your parents."
- B. "I cannot promise that. I must share this information with other members of the team who are responsible for planning your care."
- C. "I will not violate our nurse-client relationship. The information we discuss will remain confidential between us."
- D. "I can see that you trust me, but you should share those feelings with your psychiatrist, not me."
Correct Answer: B
Rationale: Duty to warn applies when a client expresses intent to harm others, requiring disclosure to the care team.
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 client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take first?
- A. Implement the client's behavioral modification plan.
- B. Document the size and location of the cuts.
- C. Assess the client's intent and suicide risk.
- D. Administer a tetanus antitoxin.
Correct Answer: C
Rationale: The correct answer is C: Assess the client's intent and suicide risk. This is the first action the nurse should take to ensure the immediate safety of the client. By assessing the client's intent and suicide risk, the nurse can determine the severity of the situation and the appropriate level of intervention needed. This assessment will guide the nurse in developing a safety plan to prevent further self-harm or potential suicide attempts.
Choice A is incorrect because implementing the client's behavioral modification plan is not the priority when the client is actively engaging in self-harm behavior.
Choice B is incorrect as documenting the size and location of the cuts can be done after ensuring the client's immediate safety.
Choice D is incorrect as administering a tetanus antitoxin is not the priority in this situation and does not address the client's emotional and psychological needs.
In summary, assessing the client's intent and suicide risk is the most critical step to ensure the client's safety and well-being in a situation involving self-h
A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder. Which of the following findings should the nurse expect?
- A. Rapid speech
- B. Tics
- C. Distorted perceptual field
- D. Urinary frequency
Correct Answer: A, D
Rationale: Moderate anxiety is associated with physical restlessness, rapid speech, and increased urinary frequency.