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A client has been compliant with antidepressant therapy but states, "The meds don't seem to be working anymore." They have no immediate family in the vicinity and are estranged from siblings, saying, "They got over me a long time ago." The client acknowledges having a few friends but expresses, "I don't want to burden them with my stuff. I'm not worth that." Which factors should the nurse consider when evaluating the client's support systems? (Select all that apply.)

Physical health

Mental health support

Alcohol consumption

Feelings of self-worth

Family history

Access to lethal means

Answer and Explanation

Correct Answer : B,D,E,F

Choice A reason: Physical health is a critical component of overall well-being and can affect mental health recovery.

Choice B reason: Mental health support, including therapy and support groups, is essential for managing depression and preventing relapse.

Choice C reason: Alcohol consumption can interfere with antidepressant efficacy and may worsen depression symptoms.

Choice D reason: Feelings of self-worth are often impacted in depression and can influence the client's motivation and engagement in treatment.

Choice E reason: Family history may provide insights into genetic predispositions and patterns that could affect the client's mental health.

Choice F reason: Access to lethal means is a significant risk factor for suicide and must be addressed in the safety planning for clients with depression.

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Correct Answer is ["B","D"]

Explanation

Choice A reason: Having two nurses present at all times may not be necessary and could be overwhelming for the client, making them feel less in control.

Choice B reason: Continuous assessment of the client's anxiety level is important to ensure that the nurse can respond to the client's needs and maintain a sense of safety.

Choice C reason: While promoting independence is good, the client may need assistance, and providing it can be part of creating a safe environment.

Choice D reason: Asking for permission is crucial as it respects the client's autonomy and helps them feel in control of their body, which is essential for someone who has experienced abuse.

Choice E reason: Having security present outside the room may be excessive and could contribute to a feeling of being guarded or watched, which may not be conducive to feeling safe and secure.

A. Increase foods high in fiber. B. Use sunscreen when outdoors. C. Use laxatives as needed. D. Develop an exercise program. E. Take double the dose at the next scheduled time for missed doses. F. Drink plenty of fruit juice.

Correct Answer is ["B","D","F"]

Explanation

Choice A reason: Increasing dietary fiber can help manage constipation, which is a common side effect of antipsychotic medications. The normal range for dietary fiber intake in adults is 25 to 30 grams per day from food, not supplements.

Choice B reason: Antipsychotic medications can increase photosensitivity, making the skin more susceptible to sunburn. Using sunscreen can help protect the skin when outdoors.

Choice C reason: While laxatives can be used to manage constipation, they should be used sparingly and only as needed to avoid dependence and potential electrolyte imbalances.

Choice D reason: Regular physical activity can help counteract weight gain, another potential side effect of antipsychotic medications. It's recommended to engage in at least 150 minutes of moderate-intensity exercise per week.

Choice E reason: Doubling the dose at the next scheduled time for missed doses is not recommended as it can lead to an overdose and exacerbate side effects.

Choice F reason: Drinking plenty of fluids, including fruit juice, can help prevent dehydration. However, it's important to monitor sugar intake from fruit juices due to the risk of weight gain.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has been a victim of abuse since childhood. Which actions by the nurse are important to ensure that the client feels safe, secure, and in control of their own body? Select all that apply.

Correct Answer is ["B","D"]

Explanation

The nurse is educating a client and family about strategies to minimize the side effects of antipsychotic drugs. Which will be included in the plan? Select all that apply.

Correct Answer is ["B","D","F"]

Explanation

The nurse provides education to a client's family about the client's eating disorder, anorexia nervosa. Which statement would indicate that the education was effective?

A client has a history of excessive fear of water. Which term should the nurse use to describe this specific phobia, and under what subtype is this phobia identified?

A nurse in a mental health clinic is conducting a staff education session on schizophrenia. Which of the following manifestations should the nurse identify as negative symptoms? Select all that apply.

A client has a history of excessive fear of water. Which term should the nurse use to describe this specific phobia, and under what subtype is this phobia identified?

The nurse is providing education to a client regarding a new prescription for lithium carbonate. Which statement by the client indicates the need for additional education?

The nurse is planning the type of approach that will be most effective in developing a therapeutic relationship with the client. With which types of personality disorders should the nurse use a matter-of-fact approach? (Select all that apply)

The nurse is talking with the spouse of a client admitted for substance use disorder and overdose. Which statement(s) made by the spouse indicates that they are exhibiting enabling behaviors? Select all that apply.