A client diagnosed with major depressive disorder with psychotic features hears voices commanding self harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time?

Placing the client on one-on-one observation while monitoring for suicidal ideations

Conducting 15minute checks to ensure safety

Encouraging the client to verbalize feelings related to suicide

Completing a room search to ensure there are no harmful objects available to the client.

Answer and Explanation

The Correct Answer is A

A. Placing the client on one-on-one observation while monitoring for suicidal ideations Given that the client is experiencing auditory hallucinations commanding self harm and is refusing to commit to a safety plan, one-on-one observation is necessary to ensure the client's safety. This

intervention provides constant monitoring and allows for immediate intervention if self harm is attempted.

B. Conducting 15minute checks to ensure safety While conducting regular safety checks is
important, in this case, more continuous monitoring is required due to the severity of the client's symptoms.

C. Encouraging the client to verbalize feelings related to suicide While encouraging communication is essential, in this urgent situation, immediate safety measures take precedence.

D. Completing a room search to ensure there are no harmful objects available to the client
Ensuring the environment is safe is important, but it should be done in conjunction with one-on- one observation to provide the highest level of safety for the client.

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Correct Answer is ["A","C","D"]

Explanation

A. Establish a healthy sleeping, eating, and exercise routine This is an important relapse prevention strategy as it promotes physical and emotional wellbeing. A structured routine helps maintain stability and reduces the risk of returning to substance use.

B. Prevent overscheduling and becoming fatigued and exhausted. Reach out to reconnect with old buddies to test strength in resistance This statement includes potential triggers for relapse (reconnecting with old buddies) and does not align with effective relapse prevention strategies.

C. Have a friend or counselor number to call when having doubts This is a valuable strategy as it provides the client with a support system and someone to reach out to during moments of doubt or vulnerability.

D. Attend outpatient and community support groups for addiction Support groups provide a sense of community, understanding, and accountability for individuals in recovery. They offer a safe space to share experiences and coping strategies, making them an essential part of relapse prevention.

A. "Maybe it's just caused by aging. This usually happens at his age." B. "The changes in his behavior came on so quickly! I wasn't sure what was happening." C. "Dad just didn't seem to know what he was doing. He has been forgetful for years." D. "Dad has always been so independent. He's lived alone for years since Mom died."

Correct Answer is B

Explanation

A) Incorrect. While aging can contribute to cognitive changes, it is not the primary factor in the acute onset of delirium.

B) Correct. This statement highlights the acute and rapid onset of behavioral changes, which is characteristic of delirium. Delirium is an acute confessional state characterized by alterations in cognition, attention, and level of consciousness. It often has a sudden onset.

C) Incorrect. Chronic forgetfulness may be indicative of dementia or other cognitive disorders, but it does not support the acute onset seen in delirium.

D) Incorrect. Independence and living alone do not directly relate to the acute onset of delirium.

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A client diagnosed with major depressive disorder with psychotic features hears voices commanding self harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is building a discharge teaching plan with a client diagnosed with substance use disorder. Which of the following relapse prevention strategies will be included in the teaching? (Select all that apply)

Correct Answer is ["A","C","D"]

Explanation

An 80 year-old client, together with his daughter, arrived at the medical surgical unit for diagnostic confirmation and management of probable delirium. Which statement by the client's daughter best supports the diagnosis?

Correct Answer is B

Explanation

Benztropine is ordered as needed (PRN) for a client taking haloperidol after being diagnosed with schizoaffective disorder. Which of the following assessments by the nurse would indicate a need for this medication?

When a client diagnosed with schizophrenia was discharged 6 months ago, haloperidol was prescribed. The client now says, "I stopped taking those pills. They made me feel like a robot." What are common side effects the nurse should validate with the client?

Which of the following is the most therapeutic response by the nurse when a client states, "I no longer need my medication since I do not hear voices"?

A newly admitted client has a diagnosis of schizoaffective disorder. Based on this diagnosis, the nurse would expect to find which of the following symptoms?

A nurse is providing teaching for a client who has schizophrenia and a new prescription for risperidone. Which of the following statements should the nurse include in the teaching?

The nurse receives report on a male client diagnosed with schizoaffective disorder and is informed that the client's verbal communication includes "circumstantiality." What intervention is most therapeutic when caring for this client?

A client asks the nurse to give her information regarding the detoxification process of alprazolam. What is the best response by the nurse?

A nurse in the emergency department is implementing a plan of care for an older adult client who is experiencing delirium tremens. Which of the following actions should the nurse take first?