A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking.

Which action should the nurse implement?

Postpone the client interview until the next day.

Document the client's paranoid behavior.

Attempt to ask the client simple questions.

Ask another nurse to talk with the client.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
Postponing the interview until the next day may not be necessary and could delay necessary assessment and care.
Choice B rationale:
Documenting the client's paranoid behavior is important but should be done after the nurse attempts to engage with the client.
Choice C rationale:
Attempting to ask the client simple questions is a non-threatening approach that allows the nurse to start the assessment and establish some rapport. It respects the client's need for space while initiating communication.
Choice D rationale:
Asking another nurse to talk with the client may be an option later if the client remains uncooperative, but the nurse should first attempt to engage with the client directly.

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Correct Answer is A

Explanation

Choice A rationale:
Exploring changes in life that have occurred after the loss is the first action the nurse should take. This allows the nurse to assess the client's grief, identify specific stressors, and understand how the loss is impacting the client's daily life and emotional well-being. It provides valuable information for tailoring further interventions and support.

Choice B rationale:
Suggesting the need for a psychiatric consultation may be premature as the nurse should first assess the client's grief and coping mechanisms. Referral for psychiatric consultation should be considered if the client's emotional distress is severe, persistent, or significantly impacting their functioning.

Choice C rationale:
Offering a referral to pastoral counseling may be appropriate for some clients, but it should not be the first action. The nurse should assess the client's needs and preferences before making such a referral.

Choice D rationale:
Encouraging attendance at a local support group can be beneficial, but it should not be the initial step. The nurse should first assess the client's current emotional state and needs to determine the most appropriate interventions.

A. Teach the client to develop a plan for daily structured activities. B. Encourage the client to exercise. C. Suggest that the client develop a list of pleasurable activities. D. Provide education on methods to enhance sleep.

Correct Answer is A

Explanation

Choice A rationale:
Teaching the client to develop a plan for daily structured activities is a key intervention for addressing major depressive disorder with symptoms like psychomotor retardation, hypersomnia, and motivation. Structured activities can help the client regain a sense of purpose, improve motivation, and gradually return to a normal level of functioning.

Choice B rationale:
Encouraging exercise is generally beneficial for mental health, but it may not be the most effective intervention for addressing the specific symptoms mentioned in this scenario.

Choice C rationale:
Suggesting the client develop a list of pleasurable activities is a valuable intervention but may not directly address the psychomotor retardation and hypersomnia seen in this case.

Choice D rationale:
Providing education on methods to enhance sleep is important, especially if hypersomnia is a symptom, but it should be part of a broader treatment plan that also includes addressing psychomotor retardation and motivation.

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A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?

Correct Answer is A

Explanation

A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

Correct Answer is A

Explanation

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Which intervention(s) should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)

A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking.

Which action should the nurse implement?