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After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping both feet while pacing the hallway. Which action should the nurse take?
- A. Instruct the client to reduce the volume of his voice.
- B. Accompany the client to a quiet area of the unit.
- C. Encourage the client to attend a support group.
- D. Administer a PRN sedative by injection.
Correct Answer: B
Rationale: Accompanying the client to a quiet area provides a calming environment, helping to deescalate the client's agitated state.
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Which individual should the nurse consider at the highest risk for suicide?
- A. A nurse who works in a pediatric emergency department.
- B. An adolescent male whose parents recently divorced.
- C. A retired older male whose significant other has passed away.
- D. A single working mother with three preschool-aged children.
Correct Answer: B
Rationale: Adolescents experiencing major life changes, such as parental divorce, are at an elevated risk for suicide due to emotional and social stressors.
A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client's rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?
- A. Disrupts group activities.
- B. Wanders into client's rooms.
- C. Talks with nonsensical words.
- D. Refuses antipsychotic medications.
Correct Answer: B
Rationale: Wandering into client's rooms poses a safety risk to both the client and others, indicating a need for constant observation to prevent potential harm.
An adolescent male who was arrested a month ago for gang-related activities has a court order to attend weekly group therapy sessions at the mental health clinic. Today his mother calls the clinic nurse to report that her son became angry last night and put his fist through a window. Which intervention is most important for the nurse to implement?
- A. Advise the mother to call the police if violent behavior occurs again.
- B. Refer the mother for psychiatric evaluation for anxiety and depression.
- C. Reinforce the need for the adolescent to attend group therapy sessions.
- D. Tell the mother to describe her feelings of helplessness to her son.
Correct Answer: A
Rationale: Advising the mother to call the police if violent behavior occurs again addresses the safety of the client and others, ensuring appropriate intervention.
A client who is an alcoholic receives a prescription for disulfiram 500 mg PO daily. Which instruction should the nurse provide to this client?
- A. Take the medication each morning beginning 48 hours after your last drink of alcohol.
- B. Take the medication with at least 8 ounces of water and limit alcohol consumption while taking this medication.
- C. Take the medication at bedtime and avoid consuming any more than one ounce of alcohol daily.
- D. Begin taking the medication immediately and take it daily, regardless of whether or not you drink alcohol.
Correct Answer: A
Rationale: Disulfiram should be taken each morning, starting 48 hours after the last drink to prevent a severe reaction, establishing a clear association between the medication and alcohol avoidance.
The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?
- A. Ask the client to describe the history of the injuries.
- B. Invite a colleague to document during the interview.
- C. Close the examination room door for privacy.
- D. Request hospital security to come to the department.
Correct Answer: C
Rationale: Closing the examination room door for privacy is the most appropriate action to create a confidential and secure environment for the client to discuss their injuries and provide a history, facilitating open communication.