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Which of the following nursing assessment data places the client at highest risk for suicide?
- A. The client feels hopeless about the future.
- B. The client has a plan in mind for suicide.
- C. The client states that death would end the misery.
- D. The client says the distress is intolerable.
Correct Answer: B
Rationale: A specific suicide plan indicates high risk, as it shows intent and means, requiring immediate intervention.
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Which therapeutic nursing intervention is most beneficial for a client diagnosed with post-traumatic stress disorder (PTSD)?
- A. Administering antianxiety medications
- B. Monitoring the client's physical symptoms
- C. Encouraging the client to express feelings
- D. Investigating the client's current family interactions
Correct Answer: C
Rationale: Expressing feelings helps process trauma, reducing PTSD symptoms by fostering emotional regulation and insight.
If the angry client is out of control and refuses a p.r.n. sedative medication, the nurse has which legal option?
- A. The nurse must respect the client's right to refuse the ordered medication.
- B. The nurse must administer the medication to protect the safety of self and others.
- C. The nurse must get permission from a probate court judge to administer the medication.
- D. The nurse should ask the hospital's attorney about the client's right to refuse treatment.
Correct Answer: A
Rationale: Clients have the right to refuse medication unless they pose an imminent danger, in which case emergency protocols may apply, but respect for autonomy is primary.
The client has been violent toward other clients on a mental health unit and interventions have failed. During the application of restraints which action by the team leader will gain the greatest cooperation from the client?
- A. Showing sympathy by apologizing for the need to restrain the client
- B. Dispassionately explaining why and how the restraints will be applied
- C. Affording the client one last opportunity to avoid restraints by “behaving”
- D. Offering to remove the restraints as soon as the client can “control the anger”
Correct Answer: B
Rationale: Explaining why and how restraints are applied (B) reduces resistance. Apologizing (A) implies mistreatment negotiating (C) undermines the decision and promising removal (D) is ineffective.
Which concept is most important for the nurse to convey to a client during a panic attack?
- A. The client is safe.
- B. The client is believed.
- C. The client is cared for.
- D. The client is accepted.
Correct Answer: A
Rationale: Reassuring safety addresses the client's fear, a core component of panic attacks, helping to de-escalate anxiety.
Staff are debriefing following the client’s violent episode. Which information should be included in the debriefing session? Select all that apply.
- A. Client’s coping mechanisms post-event
- B. The client’s history of violent behavior
- C. Adherence to instructional policies and procedures
- D. Staff’s feelings regarding the effectiveness of the team
- E. Staff’s ability to respond to the client therapeutically post-event
Correct Answer: C ,D, E
Rationale: Debriefing includes policy adherence (C) team effectiveness (D) and therapeutic response (E) to identify training needs. Client coping (A) and history (B) are not debriefing focuses.