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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.
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A young adult female client is admitted to the Emergency Department after being raped in a shopping center parking lot. The client expresses no suicidal ideation but expresses feelings of self-blame for not taking precautions when going to her car. According to theorists, such as Maslow and Erikson, this client is struggling with which issue?
- A. Self-absorption.
- B. Self-actualization.
- C. Self-control.
- D. Self-esteem.
Correct Answer: D
Rationale: Self-esteem is most related to feelings of self-blame, as the client struggles with self-worth post-trauma.
While visiting the community mental health center, a client with a diagnosis of major depressive disorder asks the nurse if what is shared with the staff will be shared with family members. How should the nurse respond to this client?
- A. Provide the client with a written hospital policy regarding privacy of information laws.
- B. Tell the client that confidentiality will be maintained, except when one's safety is threatened.
- C. Nod in the affirmative, but make no verbal commitment to the client.
- D. Assure the client that information provided will be shared with the staff only.
Correct Answer: B
Rationale: This response provides accurate information about confidentiality while acknowledging exceptions when safety is at risk, addressing the client's concern clearly.
An adolescent who is a heroin addict is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?
- A. Assess intake and output.
- B. Monitor for wheezing and apnea.
- C. Limit visitors to family members only.
- D. Assign the client to a teen support group.
Correct Answer: B
Rationale: Monitoring for wheezing and apnea is crucial during the first 24 hours of heroin detoxification to ensure respiratory stability, addressing immediate physiological risks.
The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?
- A. A young woman who suddenly goes blind with no indication of organic pathology.
- B. An older adult who continuously complains of a headache and back pain.
- C. An adolescent who becomes extremely anxious about going outside.
- D. A middle-aged man who is complaining of shortness of breath and is diaphoretic.
Correct Answer: A
Rationale: Sudden blindness with no organic pathology is indicative of a conversion disorder, involving neurological symptoms without a neurological basis.
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.