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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.
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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.
During the admission assessment to the mental health unit, a client reports that the people at the office, where the client works, are antagonistic and the client is thinking of shooting the supervisor. The client asks the nurse not to reveal this to anyone else. The nurse immediately notifies the client's therapist and other team members of the client's thoughts. The therapist then calls the client's supervisor and shares the client's thoughts about shooting the supervisor. Which outcome is best based on the action of the nurse?
- A. The nurse is reprimanded for divulging confidential patient information without obtaining informed consent
- B. Both the nurse and therapist are reprimanded for divulging confidential patient information to others
- C. The nurse and therapist will be asked to educate other team members on appropriate sharing of client information
- D. The therapist is reprimanded for divulging confidential patient information without obtaining consent
Correct Answer: C
Rationale: The nurse appropriately shared the threat with the team to ensure safety, but the therapist's disclosure to the supervisor may breach confidentiality. Educating team members on appropriate information sharing balances safety and privacy. Reprimands are less constructive unless clear violations occurred.
The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in depth with the client based on this screening tool?
- A. Efforts to cut down, annoyance with questions, guilt, drinking as an 'Eye-opener'
- B. Consumption, liver enzyme, gastrointestinal complaints and bleeding
- C. Cancer screening results, anger, gastritis, daily alcohol intake
- D. Minimizes drinking, frequently misses family events, guilt about drinking, amount of daily intake
Correct Answer: A
Rationale: The CAGE questionnaire focuses on four key aspects: efforts to Cut down, Annoyance with questions, Guilt about drinking, and Eye-opener use. Exploring these provides insight into potential alcohol problems. Other options include relevant aspects but are not specific to the CAGE questionnaire.
The nurse continues to care for the patient
The client is a 19-year-old male who is in the emergency room for a leg injury. He states he was returning to his dorm from a party and fell about 5 feet (1.5 meters) into a small ravine on campus. The client states that he drinks socially and takes no medications for any health condition.
The nurse is listening to the client.
Because the client is a male, he is especially at risk for which psychosocial two sequalae of sexual assault?
- A. Suicide
- B. Depression
- C. Post-traumatic stress disorder
- D. Becoming an abuser
- E. Human immunodeficiency virus
- F. Chlamydia
Correct Answer: B,C
Rationale: B: Depression is common post-sexual assault due to psychological trauma. C: PTSD is frequent, with symptoms like flashbacks and anxiety. A: Suicide is a risk but not male-specific. D: Becoming an abuser is less common. E, F: HIV and chlamydia are physical, not psychosocial, risks.
Following involvement in a motor vehicle collision, a middle-aged adult client is admitted to the hospital with multiple facial fractures. The client's blood alcohol level is high on admission. Which PRN prescription should be administered if the client begins to exhibit signs and symptoms of delirium tremens (DTs)?
- A. Prochlorperazine 5 mg IM
- B. Hydromorphone 2 mg IM
- C. Lorazepam 2 mg IM
- D. Chlorpromazine 50 mg IM
Correct Answer: C
Rationale: Lorazepam is a benzodiazepine used to manage delirium tremens (DTs), a severe form of alcohol withdrawal, by reducing agitation and preventing seizures. Prochlorperazine and chlorpromazine are antipsychotics, not first-line for DTs. Hydromorphone is an opioid and inappropriate for DTs management.