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During a family group meeting, the client's daughter tells the group, 'I hope I didn't cause Mom to be depressed.' Which response is best for the nurse to provide?
- A. I hear you say you worry about causing your mother's distress
- B. Are you afraid that your mother's depression will lead to her death?
- C. What do you think you did that led to your mother's depression?
- D. You are not alone in feeling responsible for others in your family
- E. You are not alone in feeling responsible for others in your family
Correct Answer: A
Rationale: This response acknowledges the daughter's feelings without assumptions or blame, fostering open communication. The second option escalates anxiety. The third may encourage self-blame. The fourth generalizes without addressing her specific concern.
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An adolescent 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 the adolescent's mother calls the clinic nurse to report that her child became angry last night and put a fist through a window. Which intervention is most important for the nurse to implement?
- A. Reinforce the need for the adolescent to attend group therapy sessions
- B. Tell the mother to describe her feelings of helplessness to her child
- C. Advise the mother to call the police if violent behavior occurs again
- D. Refer the mother for psychiatric evaluation for anxiety and depression
Correct Answer: C
Rationale: Advising the mother to call the police if violent behavior recurs prioritizes safety for the adolescent and household. Therapy attendance is important but secondary to immediate safety. Discussing the mother's feelings or referring her for evaluation does not address the acute risk.
A client is admitted to the mental health unit with a bipolar disorder. When seeking to establish a therapeutic relationship and interacting with the client, which comment is best for the nurse to make?
- A. I understand that you're angry and unhappy. Let's explore ways in which you overreact
- B. I hear your frustration about losing control. Tell me how this affects your daily life
- C. Knowing the cause of your symptoms will make them easier to handle
- D. Do all that you can to learn all that you can while you are here. You can get better
Correct Answer: B
Rationale: This response acknowledges the client's feelings and invites further exploration, fostering a therapeutic relationship. The first option may invalidate feelings by assuming overreaction. The third shifts focus from immediate concerns. The fourth is encouraging but does not address current feelings.
Which intervention(s) should the nurse include in the plan of care for an adolescent client who is depressed? Select all that apply.
- A. Restrict visitors to family members only
- B. Reinforce statements regarding a will to live and realistic plans for the future
- C. Discuss the client's suicide plan
- D. Encourage the client to discuss thoughts and feelings
- E. Limit time allowed to play video games
Correct Answer: B,C,D
Rationale: B: Reinforcing statements about a will to live provides hope. C: Discussing a suicide plan assesses risk and ensures safety. D: Encouraging discussion of thoughts and feelings promotes therapeutic communication. A: Restricting visitors may increase isolation. E: Limiting video games is less relevant to immediate depression management.
In conducting the initial assessment of a preoperative client, the nurse notes that the client's home medications include the monoamine oxidase (MAO) inhibitor phenelzine. Because of this client's medication history, which assessment finding is most important for the nurse to monitor?
- A. Blood pressure
- B. Urinary output
- C. Respiratory rate
- D. Temperature
Correct Answer: A
Rationale: MAO inhibitors like phenelzine can cause hypertensive crises, especially with certain foods or medications. Monitoring blood pressure is critical to detect this life-threatening complication. Urinary output, respiratory rate, and temperature are less directly affected by MAO inhibitors.
A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?
- A. Ineffective sexual patterns
- B. Disturbed sensory perception
- C. Compromised family coping
- D. Impaired environmental interpretation
Correct Answer: B
Rationale: The client's delusions (e.g., being married to a movie star, brother's intentions) indicate disturbed sensory perception, suggestive of psychosis, which is the priority. Ineffective sexual patterns are not directly indicated. Family coping may be secondary. Impaired environmental interpretation is too broad.