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Which is the best approach for the nurse to use when interviewing a client about suicidal ideations?
- A. Share personal values to put the client at ease
- B. Ask questions in a vague, non-specific format
- C. Begin with questions that are less sensitive in nature
- D. Get the most difficult questions over with first
Correct Answer: C
Rationale: Beginning with less sensitive questions allows the client to gradually build trust and rapport with the nurse before addressing more sensitive topics like suicidal ideation. Sharing personal values may blur professional boundaries. Vague questions may not yield accurate information. Starting with difficult questions may overwhelm the client and hinder trust.
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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.
A client requests permission for the spouse to remain in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. Which action should the nurse take?
- A. Ignore the nonverbal behavior and focus on the client's verbal messages
- B. Integrate the verbal and nonverbal messages and interpret them as one
- C. Ask the client's spouse to interpret the discrepancy
- D. Pay close attention and document the nonverbal messages
Correct Answer: D
Rationale: Paying close attention and documenting nonverbal messages gathers comprehensive data for further exploration. Ignoring nonverbal cues misses important information. Integrating messages prematurely may misinterpret the discrepancy. Asking the spouse to interpret is inappropriate and may not be accurate.
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.
A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?
- A. Ineffective sexual patterns
- B. Disturbed sensory perception
- C. Compromised family coping
- D. Impaired environmental interpretation
Correct Answer: B
Rationale: The client's delusions (e.g., being married to a movie star, brother's intentions) indicate disturbed sensory perception, suggestive of psychosis, which is the priority. Ineffective sexual patterns are not directly indicated. Family coping may be secondary. Impaired environmental interpretation is too broad.
A client engages in repeated checks of door and window locks and behavior that prevents the client from arriving on time and interfering with the ability to function effectively. Which action should the nurse take?
- A. Determine the type and size of the locks
- B. Plan a list of activities to be carried out daily
- C. Discuss checking the time frequently
- D. Ask the client why the locks are checked so frequently
Correct Answer: B
Rationale: Planning a list of daily activities helps establish a structured routine, reducing time spent on compulsive checking and promoting effective functioning. Determining lock types is irrelevant. Discussing time-checking does not address lock-checking. Asking 'why' may increase frustration, as compulsive behaviors are anxiety-driven.