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The nurse accepts a transfer to the mental health unit and understands that the client is distractible and is exhibiting a decreased ability to concentrate. The nurse has only 15 minutes to talk with the client. To develop a treatment plan for this client, which assessment is most important for the nurse to obtain?
- A. Motivation for treatment
- B. History of substance use
- C. Medication compliance
- D. Mental status examination
Correct Answer: D
Rationale: A mental status examination is the most important assessment for the nurse to obtain in this scenario. It provides a comprehensive view of the client's current cognitive functioning, including their level of alertness, orientation, memory, attention, and thought process. Understanding the client's mental status is crucial for developing an appropriate treatment plan. The other options, such as motivation for treatment, history of substance use, and medication compliance, are important aspects to consider but may not directly address the client's current cognitive state and immediate treatment needs as effectively as a mental status examination.
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A male adolescent was admitted to the unit two days ago for depression. When the mental health nurse tries to interview the client to establish rapport, he becomes very irritated and sarcastic. Which action is best for the nurse to take?
- A. Offer to play a game of cards with the client.
- B. Report the behavior to the next shift.
- C. Document the behavior in the chart.
- D. Plan to talk with the client the next day.
Correct Answer: A
Rationale: Offering to play a game of cards with the adolescent is the best action for the nurse to take in this situation. Engaging in an activity like playing a game can help establish rapport with the adolescent as it provides a more relaxed and non-threatening environment for communication. This approach can help the adolescent feel more comfortable and open up, as adolescents often find it easier to communicate when involved in an activity. Reporting the behavior to the next shift, documenting the behavior, or planning to talk with the client the next day do not directly address the immediate need to establish rapport and improve communication with the adolescent.
The nurse is planning client teaching for a 35-year-old client with early alcoholic cirrhosis. Which self-care measure should the nurse emphasize for the client's recovery?
- A. Support group meetings.
- B. Vitamin B and multivitamin supplements.
- C. Diet with adequate calories and protein.
- D. Alcohol abstinence.
Correct Answer: D
Rationale: Alcohol abstinence is the most critical self-care measure for a client with early alcoholic cirrhosis. Continued alcohol consumption can lead to further liver damage and worsen the condition. Support group meetings may offer emotional support but do not address the root cause of the issue. While vitamin supplements and a nutritious diet are important for overall health, alcohol abstinence takes precedence in managing cirrhosis caused by alcohol consumption.
A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client's plan of care should include what priority problem?
- A. Acute confusion.
- B. Ineffective community coping.
- C. Disturbed sensory perception.
- D. Self-care deficit.
Correct Answer: A
Rationale: Acute confusion is the priority problem because it directly impacts the client's safety and functioning. In this scenario, the client is disoriented, disorganized, and confused, which can pose immediate risks to her well-being. Ineffective community coping, disturbed sensory perception, and self-care deficit are not as urgent in this situation. Ineffective community coping focuses on the client's ability to manage stress related to the community, disturbed sensory perception pertains to alterations in sensory input, and self-care deficit involves the inability to perform activities of daily living independently. While these issues may also need addressing, acute confusion takes precedence due to the immediate safety concerns it presents.
A female client with a history of major depressive disorder is experiencing a worsening of symptoms. Which statement by the client indicates a potential risk for suicide?
- A. "I've been feeling more tired than usual."
- B. "I've been thinking about how much better everyone would be without me."
- C. "I've been having trouble sleeping lately."
- D. "I feel like I can't handle everything."
Correct Answer: B
Rationale: The client's statement about thinking that everyone would be better off without her indicates suicidal ideation. This statement is a significant warning sign for suicide risk and requires immediate intervention. Choices A, C, and D reflect common symptoms of depression but do not directly indicate suicidal thoughts or intentions. Feeling tired, having trouble sleeping, and feeling overwhelmed are typical symptoms of major depressive disorder but do not necessarily suggest an imminent risk of suicide like the statement in option B does.
A client who has a history of bipolar disorder is recovering from a manic episode and is now experiencing depressive symptoms. Which action should the nurse take first?
- A. Assess the client for suicidal ideation.
- B. Provide a detailed schedule of daily activities.
- C. Discuss the importance of medication adherence.
- D. Encourage the client to engage in group therapy.
Correct Answer: A
Rationale: Assessing for suicidal ideation is the priority when a client with bipolar disorder is transitioning from a manic episode to a depressive phase. Suicidal ideation is a critical concern during depressive episodes, and ensuring the client's safety is the top priority. Providing a detailed schedule of daily activities (Choice B) may be helpful but is not the immediate priority over assessing for suicidal ideation. Discussing the importance of medication adherence (Choice C) and encouraging group therapy (Choice D) are essential components of care but are secondary to ensuring the client's safety in the context of potential suicidal ideation.