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The mother of an 8-month-old infant with profound mental and physical disabilities tells the nurse how depressed she is because she realizes that her child will never achieve normal growth and development milestones. How should the nurse respond to this mother?
- A. Encourage the mother to write thoughts and feelings in a journal.
- B. Determine if the mother has other children who do not have developmental disabilities.
- C. Reassure the mother that her child will achieve some growth and development milestones.
- D. Ask the mother if she has ever thought about harming herself or her child.
Correct Answer: D
Rationale: Asking about thoughts of self-harm or harm to the child assesses the severity of depression and risk, a critical first step. [Note: Document incorrectly lists A; D is more appropriate for safety.]
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The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?
- A. Bradycardia and bradypnea.
- B. Stimulation and dilated pupils.
- C. Hallucinations and delusions.
- D. Lethargy and depression.
Correct Answer: B
Rationale: Cocaine, a stimulant, typically causes stimulation, increased heart rate, and dilated pupils. Bradycardia/bradypnea, hallucinations/delusions, or lethargy/depression are less common or associated with withdrawal/overdose.
A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?
- A. Concentrate on and ventilate emotions when distressed.
- B. Shift attention from self to the needs and requests of others.
- C. Relax and reduce the amount of effort to solve the problem.
- D. Focus on small achievable tasks, not taxing problems.
Correct Answer: D
Rationale: Focusing on small achievable tasks can reduce feelings of overwhelm and improve self-efficacy in a client with depression. Ventilating emotions may exacerbate distress, shifting attention may neglect personal needs, and relaxation may perpetuate helplessness.
The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?
- A. Five-pound (2.3 kg) weight gain.
- B. Nausea and vomiting.
- C. Short-term memory loss.
- D. Depressed affect.
Correct Answer: B
Rationale: Nausea and vomiting may indicate lithium toxicity, requiring immediate reporting. Other symptoms are concerning but less urgent.
A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?
- A. Postpone the client interview until the next day.
- B. Document the client's paranoid behavior.
- C. Attempt to ask the client simple questions.
- D. Ask another nurse to talk with the client.
Correct Answer: C
Rationale: Attempting to ask the client simple questions is a non-threatening approach that allows the nurse to start the assessment and establish rapport. Postponing delays care, documenting should follow engagement, and involving another nurse is a later option.
A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?
- A. Assist the client with relaxation techniques in the group.
- B. Escort the client from the group to reduce stimuli.
- C. Provide education about ways to cope with anxiety.
- D. Ask the client to describe and identify the source of the feelings.
Correct Answer: A
Rationale: Assisting with relaxation techniques in the group provides immediate anxiety relief and support, suitable for acute anxiety.