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 C

Explanation

A) Incorrect. While discussing various topics is important, providing continuity of care is more crucial in creating a therapeutic environment for clients with paranoia and schizophrenia.

B) Incorrect. Focusing on client strengths rather than weaknesses is generally a more effective approach in mental health care.

C) Correct. Providing continuity of care by assigning the same staff helps build trust and a sense of security for clients, especially those with paranoia and schizophrenia.
D) Incorrect. While it's important to establish boundaries, allowing the client to solely determine them may not always be in their best interest.

A. Anhedonia B. Aphasia C. Akathisia D. Agnosia

Correct Answer is D

Explanation

A. Anhedonia is a symptom commonly associated with depression, characterized by a decreased ability to experience pleasure or interest in activities.

B. Aphasia is a language disorder that affects the ability to communicate. It may involve difficulty in speaking, understanding language, reading, or writing. This is not demonstrated in the scenario.

C. Akathisia is a side effect of some antipsychotic medications characterized by a feeling of inner restlessness and the need to move constantly. It is not demonstrated in the scenario.

D. Agnosia is a symptom of dementia characterized by the inability to recognize familiar objects, people, or places, despite the senses being intact. In this scenario, the client's inability to recognize that their glasses are not a form of identification indicates agnosia.

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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

A nurse is planning to run a group for clients diagnosed with paranoia and schizophrenia on an acute care mental health unit. Which of the following actions should the nurse plan to take to create a therapeutic environment?

Correct Answer is C

Explanation

During the admission process, an elderly client is asked to present their license for identification purposes. The client gives the admission personnel their glasses. This is an example of which of the following symptoms of dementia?

Correct Answer is D

Explanation

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