A client was admitted to the intensive care unit after a single car accident in which he struck a cement wall. He is now responsive and wants to be discharged within the next couple of days. Which of the following are priorities for screening? (Select all that apply)

Traumatic brain injury

Chronic pain

Sexual Dysfunction

Depression

Effective coping strategies

Risk for suicide

Answer and Explanation

Correct Answer : A,D,F

A) Correct. Given the nature of the accident, there is a high risk for traumatic brain injury. This should be a priority for screening and assessment.

B) Incorrect. While chronic pain may be a concern, it is not directly related to the recent accident and is not a priority for screening at this time.

C) Incorrect. Sexual dysfunction is not directly related to the recent accident and is not a priority for screening at this time.

D) Correct. The client's request for early discharge and the recent traumatic event raise concerns about potential depression. Screening for depression is important.

E) Incorrect. Effective coping strategies are important, but they are not a priority for screening in this scenario.

F) Correct. Given the recent accident and the client's expressed desire for early discharge, there may be an increased risk for suicide. This should be a priority for screening and assessment.

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Correct Answer is B

Explanation

A) Incorrect. While understanding the reasons behind the suicidal thoughts is important, in this immediate situation, assessing access to means (medications) is crucial.

B) Correct. This question assesses the immediate risk by determining if the friend has access to the means (medications) to carry out the overdose.

C) Incorrect. While substance use is a risk factor, it may not directly address the immediate threat of overdose with pills.

D) Incorrect. While family issues can contribute to emotional distress, the most pressing concern is the immediate risk of overdose.

A. Clients who have received long-term neuroleptic treatment. B. Clients who have discontinued their neuroleptic treatment. C. Clients who have experienced neuroleptic malignant syndrome (NMS). D. Clients who have received monoamine oxidase inhibitors (MAOIS).

Correct Answer is A

Explanation

A) Correct. Tardive dyskinesia is a side effect of long-term neuroleptic (antipsychotic) treatment. It is characterized by involuntary, repetitive movements, particularly of the face and tongue. This condition is more commonly seen in clients who have been on neuroleptics for extended periods.

B) Incorrect. Discontinuing neuroleptic treatment may lead to withdrawal symptoms or symptom recurrence, but it does not directly increase the risk of developing tardive dyskinesia.

C) Incorrect. Neuroleptic malignant syndrome (NMS) is a different side effect associated with neuroleptic medications, characterized by hyperthermia, autonomic dysregulation, altered mental status, and generalized muscle rigidity.

D) Incorrect. Monoamine oxidase inhibitors (MAOIs) are a different class of medications and are not associated with the development of tardive dyskinesia.

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A client was admitted to the intensive care unit after a single car accident in which he struck a cement wall. He is now responsive and wants to be discharged within the next couple of days. Which of the following are priorities for screening? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adolescent tells the school nurse, "My friend threatened to take an overdose of pills." The nurse talks to the friend who verbalized the suicide threat. What is the most critical question for the nurse to ask?

Correct Answer is B

Explanation

What client population is at risk of developing tardive dyskinesia?

Correct Answer is A

Explanation

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?

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