Nokea
Which individual should the nurse consider at the highest risk for suicide?
- A. A nurse who works in a pediatric emergency department.
- B. An adolescent male whose parents recently divorced.
- C. A retired older male whose significant other has passed away.
- D. A single working mother with three preschool-aged children.
Correct Answer: B
Rationale: Adolescents experiencing major life changes, such as parental divorce, are at an elevated risk for suicide due to emotional and social stressors.
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When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client's record should the nurse review?
- A. The healthcare provider's history and physical.
- B. Recent urine drug testing (UDT) results.
- C. Baseline nursing admission assessment.
- D. Abnormal Involuntary Movement Scale (AIMS).
Correct Answer: D
Rationale: The Abnormal Involuntary Movement Scale (AIMS) is specifically designed to assess and document involuntary movements associated with psychotropic medications, making it the most relevant assessment tool for these symptoms.
During a one-to-one session with the nurse, a female client admitted for chronic depression and attempted suicide discloses experiences of sexual promiscuity and prostitution. When the nurse asks the client if she was ever sexually abused as a child, the client says, “I don't remember, but my mother ran my father off when I was five.†The nurse should recognize that the client may be using which defense mechanism?
- A. Regression.
- B. Projection.
- C. Denial.
- D. Repression.
Correct Answer: D
Rationale: Repression involves unconsciously blocking out memories, and the client's inability to recall potential abuse suggests this defense mechanism.
After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping both feet while pacing the hallway. Which action should the nurse take?
- A. Instruct the client to reduce the volume of his voice.
- B. Accompany the client to a quiet area of the unit.
- C. Encourage the client to attend a support group.
- D. Administer a PRN sedative by injection.
Correct Answer: B
Rationale: Accompanying the client to a quiet area provides a calming environment, helping to deescalate the client's agitated state.
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.
An adolescent who is exhibiting a depressed affect receives a prescription for an antidepressant drug. While the client is taking the antidepressant, which comparison of the client's behavior before and after taking the drug is most important for the nurse to obtain?
- A. Level of activity.
- B. The interactions with others.
- C. The emotional quality of attitude.
- D. Appetite.
Correct Answer: C
Rationale: The emotional quality of attitude reflects the client's internal state and is a key indicator of the antidepressant's impact on their depressive symptoms, making it the most critical aspect to assess.