A client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting self injury by shooting. The client reports going through a divorce one year ago, job loss four months ago, and suffering from a breakup of a current relationship last week. Which is the most likely source of this client's current feelings of depression?

Feelings of frustration.

A sense of loss.

Poor self-esteem.

A lack of intimate relationships.

Answer and Explanation

The Correct Answer is B

Choice A rationale: While frustration may contribute to distress, the client's recent life events, such as a breakup and job loss, suggest a stronger link to a sense of loss.

Choice B rationale: Experiencing a divorce, job loss, and recent breakup are significant life events that contribute to a profound sense of loss, which can lead to feelings of depression.

Choice C rationale: Poor self-esteem can contribute to depression, but the client's recent life events are more directly related to the current feelings of depression.

Choice D rationale: While a lack of intimate relationships can impact mental health, the recent breakup is a more immediate factor contributing to the client's depression.

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Correct Answer is C

Explanation

Choice A rationale: Reports difficulties with short-term memory since a traumatic brain injury is not an indication for using the CAGE questionnaire. The CAGE questionnaire is specifically designed to screen for alcohol use disorder.

Choice B rationale: Medical history, including recent sexual assault, does not directly correlate with the need for the CAGE questionnaire. The CAGE questionnaire focuses on identifying problematic alcohol use.

Choice C rationale: Describing self as a social drinker who drinks alcoholic beverages daily is an indication for using the CAGE questionnaire. The client's daily consumption and identification as a social drinker raise concerns about potential alcohol misuse or dependency.

Choice D rationale: Client's medication history, including the frequent use of antidepressants, is not an indication for using the CAGE questionnaire. The CAGE questionnaire is specific to alcohol use and does not address antidepressant use.

A. Gastric lavage. B. Renal dialysis. C. Nebulizing with albuterol. D. Administration of naloxone.

Correct Answer is D

Explanation

Choice A rationale: Gastric lavage may be considered, but the priority is to address respiratory depression. Naloxone administration is more immediate.

Choice B rationale: Renal dialysis is not indicated for the overdose of methadone and benzodiazepines. Addressing respiratory depression is the priority.

Choice C rationale: Nebulizing with albuterol is not the appropriate intervention for respiratory depression due to drug overdose. Naloxone administration is more critical. Choice D rationale: Administration of naloxone is the priority for this client with respiratory depression due to the potential opioid overdose (methadone). Naloxone is an opioid antagonist that can reverse opioid-induced respiratory depression.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client Information indicates the need for the nurse to use the CAGE questionnaire during the admission interview?

Correct Answer is C

Explanation

A client is admitted to the emergency department because of a possible overdose of methadone and benzodiazepines. The admission respiratory rate is 6 breaths/minute. Based on this finding, the nurse should prepare for which intervention?

Correct Answer is D

Explanation

A client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because of a stalker. Which action is most important for the nurse to take?

A client with obsessive compulsive disorder (OCD) reports feeling "driven" to check the locks on the front door at least six times every night. Which response is best for the nurse to provide?

During admission to the psychiatric unit, a client is extremely anxious and reports being worried about the sun coming up the next day. Which intervention is most important for the nurse to implement during the admission process?

A client who is experiencing a severe level of anxiety and reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?

The nurse interacts with a client who is very depressed and slow to respond to questions. The nurse asks the client to describe current feelings, but the client looks down at the table. Which action is best for the nurse to implement?

After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy. Which action should the nurse implement?