Nokea
Which individual should the nurse consider at highest risk for suicide?
- A. A retired older male whose significant other has passed away
- B. A nurse who works in a pediatric emergency department
- C. An adolescent male whose parents recently divorced
- D. A single working mother with three pre-school aged children
Correct Answer: C
Rationale: Adolescents experiencing significant life changes like parental divorce are at increased suicide risk due to emotional upheaval and limited coping skills. Older males may have coping mechanisms. Stressful jobs or parenting are less specific risk factors without additional context.
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The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?
- A. You appear to be speaking with someone
- B. Let's talk about the next time this happens
- C. You need to be calm and focus on something else
- D. The voices you are hearing are not real
Correct Answer: A
Rationale: This comment acknowledges the client's behavior without judgment, validating their experience and encouraging further discussion. Focusing on the future, redirecting, or denying the voices may not be therapeutic and could invalidate the client's reality.
The nurse is performing the admission assessment for a client with schizophrenia in an acute care inpatient facility. The nurse should identify which observed behavior is characteristic of schizophrenia?
- A. Responds with illogical answers to questions
- B. Admits to frequently thinking about committing suicide
- C. Describes times of depression followed by feelings of euphoria
- D. Exhibits compulsive, ritualistic behaviors
Correct Answer: A
Rationale: Responding with illogical answers indicates disorganized thinking, a hallmark of schizophrenia during psychosis. Suicide thoughts are not specific to schizophrenia. Depression and euphoria suggest bipolar disorder. Compulsive behaviors are more typical of OCD.
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. Relax and reduce the amount of effort to solve the problem
- C. Shift attention from self to the needs and requests of others
- D. Focus on small achievable tasks, not taxing problems
Correct Answer: D
Rationale: Focusing on small achievable tasks promotes a sense of accomplishment, counteracting helplessness and supporting behavioral activation for depression. Ventilating emotions may not address avoidance. Reducing effort may worsen helplessness. Shifting attention to others does not directly address depressive symptoms.
A male client with a recent diagnosis of bipolar disorder takes lithium carbonate daily. The client informed the school nurse of the desire to live away from home to attend college after graduating in one month. Which information is most important for the nurse to provide the client and his family?
- A. The client should plan to participate in group or individual therapy while at college
- B. The client's serum lithium levels should be routinely evaluated
- C. The client should be aware of the signs and symptoms of his illness
- D. Despite the illness, the client should be able to live away from home
Correct Answer: B
Rationale: Lithium therapy requires regular monitoring of serum levels to ensure therapeutic efficacy and prevent toxicity, especially during transitions like starting college. Therapy and symptom awareness are important but secondary to lithium level monitoring. Independence is a goal but not the primary focus.
A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determine the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?
- A. Ineffective community coping
- B. Disturbed sensory perception
- C. Self-care deficit
- D. Acute confusion
Correct Answer: D
Rationale: Acute confusion is the priority problem because the client is disoriented, disorganized, and confused, indicating a cognitive impairment that needs immediate attention. Ineffective community coping may be a concern for a homeless individual but is not the priority in this scenario. Disturbed sensory perception typically involves alterations in visual, auditory, tactile, or olfactory senses, which may not be the primary issue. While self-care deficit could be a concern, it is not the priority when the client is disoriented.