Nokea
A nurse on a mental health unit is caring for clients who have various depressive disorders. The nurse should identify which of the following client diagnoses as presenting the greatest risk for suicide?
- A. Premenstrual dysphoric disorder
- B. Seasonal affective disorder
- C. Major depressive disorder
- D. Persistent depressive disorder
Correct Answer: C
Rationale: The correct answer is C: Major depressive disorder. Clients with major depressive disorder are at the highest risk for suicide due to the severity of their symptoms, including feelings of hopelessness, worthlessness, and suicidal ideation. This diagnosis is associated with a higher rate of completed suicides compared to other depressive disorders. Clients with premenstrual dysphoric disorder (A) experience mood changes related to their menstrual cycle but do not typically have an increased risk of suicide. Seasonal affective disorder (B) is characterized by seasonal changes in mood and energy levels but is not typically associated with a high risk of suicide. Persistent depressive disorder (D) involves chronic depressive symptoms but does not necessarily indicate an increased risk of suicide.
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A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?
- A. Determining if the client has psychotic thinking
- B. Asking the client to identify the cause of the crisis
- C. Identifying the client's coping skills
- D. Identifying the client's support systems
Correct Answer: A
Rationale: The correct answer is A: Determining if the client has psychotic thinking. This is the highest priority because it directly addresses the client's immediate safety and well-being. Psychotic thinking can pose a significant risk to the client and others, requiring prompt intervention. Asking the client to identify the cause of the crisis (B), identifying coping skills (C), and support systems (D) are important but secondary to ensuring the client's safety. It is crucial to address any potential psychotic thinking first before delving into other aspects of the assessment.
A home health nurse is speaking to a group of acute care nurses about domestic violence. Which of the following statements by one of the acute care nurses indicates a need for clarification?
- A. "I have heard that abusers try to keep their partner isolated from others."
- B. "I know that abusers lack social supports and social skills."
- C. "I know that men who are abusers gain power through intimidation."
- D. "I have heard that abusers think of themselves as important and have high self-esteem."
Correct Answer: D
Rationale: Answer D indicates a need for clarification because it presents a misconception about abusers. Abusers typically have low self-esteem and use power and control to compensate. This statement falsely suggests that abusers have high self-esteem and view themselves as important. This misunderstanding could lead to overlooking warning signs and risks associated with domestic violence. It's crucial for healthcare professionals to recognize the true dynamics of abusive relationships to provide appropriate support and interventions. Other choices (A, B, C) align with common knowledge about domestic violence, highlighting the tactics and behaviors typically associated with abusers.
A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?
- A. "You are being unreasonable, and I will not call your doctor at this hour."
- B. "I can't call a doctor in the middle of the night unless it's an emergency."
- C. "Go back to your room, and I'll try to get in touch with your doctor."
- D. "You must be very upset about something."
Correct Answer: D
Rationale: The correct answer is D: "You must be very upset about something." This response is appropriate because it acknowledges the client's emotions and demonstrates empathy. It shows the nurse's understanding of the client's distress, which is crucial in building a therapeutic relationship. By validating the client's feelings, the nurse can de-escalate the situation and gather more information to address the client's needs effectively.
Choice A is incorrect because it dismisses the client's request and can escalate the situation. Choice B is incorrect as it fails to acknowledge the client's emotions and lacks empathy. Choice C is incorrect as it does not address the client's emotional state and may lead to further agitation.
A nurse is caring for an adolescent who is experiencing indications of depression. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Irritability
- B. Euphoria
- C. Chronic pain
- D. Social withdrawal
- E. Changes in appetite
Correct Answer: A, C, D, E
Rationale: Depression in adolescents often presents with irritability, physical complaints (chronic pain), social withdrawal, and appetite changes.
A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain about the client's disruptive behaviors. Which of the following initial actions should the nurse take?
- A. Talk to the nursing staff.
- B. Talk to the client and identify the specific limits that are required of the client's behavior.
- C. Discuss the problem in a community meeting with the other clients on the unit present.
- D. Escort the client to her room each time the nurse observes the client socializing with others.
Correct Answer: B
Rationale: The correct initial action for the nurse to take is choice B: Talk to the client and identify the specific limits that are required of the client's behavior. This option is the most appropriate because it directly addresses the client's behavior and sets clear expectations. By having a one-on-one conversation with the client, the nurse can establish boundaries and consequences for disruptive behavior, which may help modify the client's actions. Talking to the nursing staff (choice A) may be necessary later, but addressing the client directly is the first step. Discussing the problem in a community meeting (choice C) may embarrass the client and not address the behavior directly. Escorting the client to her room (choice D) does not address the underlying issue of lying and disruptive behavior.