A client with depression is admitted for voluntary treatment. While in the hospital, the client makes several comments about leaving the facility and kiling themselves with their gun. Which is the most appropriate action by the nurse when the client requests to leave against medical advice?

Call security and ask them to detain the client from leaving.

Contact the client's family to request they convince the client to stay.

Allow the client to leave, with a referral to community resources for follow-up care.

Contact the psychiatrist for initiation of commitment proceedings.

Answer and Explanation

The Correct Answer is D

In this situation, the client's safety is of utmost importance. Expressing a desire to leave the facility and harm oneself with a gun raises serious concerns about the client's safety and the risk of harm to themselves. Initiating commitment proceedings, also known as involuntary hospitalization or psychiatric hold, allows the facility to legally detain the client temporarily for their protection and evaluation by mental health professionals. This allows for a thorough assessment of the client's mental health status and the formulation of a comprehensive treatment plan to ensure their safety.

Options A, B, and C are not appropriate in this situation:

A. Calling security to detain the client may escalate the situation and could potentially lead to increased risk of harm.

B. Contacting the client's family may not be enough to ensure the client's safety, and it is essential to involve mental health professionals in evaluating the client's risk.

C. Allowing the client to leave without addressing their expressed suicidal ideation is not safe, as the client may be at high risk for self-harm or suicide. Simply referring them to community resources without further evaluation and intervention is not sufficient to address the immediate safety concern.

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

Explanation

Complicated grieving, also known as complicated grief or prolonged grief disorder, refers to a type of grief that is prolonged, intense and does not follow the typical trajectory of mourning. It can manifest differently in different individuals, but some common signs of complicated grieving include:

B. An adult who insisted for many years that the adult hated the adult's deceased parent: This could indicate unresolved emotional conflicts with the deceased parent, which may be contributing to complicated grief.

C. The parent of a child who died after having left the child in a car on a hot day: This situation involves feelings of guilt and responsibility, which can complicate the grieving process.

D. The grandchild of a soldier killed in war who visits the grave once a year on Memorial Day: This response is likely a normal grief response, as the person visits the grave once a year during Memorial Day, which is a common time for remembering and honoring deceased loved ones.

The following options are not necessarily indicative of complicated grieving:

A. A driver whose spouse and children all died as a result of his driving drunk: While this is undoubtedly a traumatic event, the description provided does not necessarily indicate complicated grieving specifically.

E. The spouse of a person who died 7 years ago and visits the grave several times a day: Visiting the grave several times a day might indicate a deep sense of loss, but it is not specific to complicated grieving and can vary depending on cultural practices and individual coping mechanisms.

It's essential to recognize that grief is a complex and individual process, and professional assessment and support are often required to identify and address complicated grieving in a person.

A. Blood pressure B. Cyanosis C. Nausea D. Petechiae

Correct Answer is C

Explanation

Objective data:

Blood pressure (can be measured by the nurse)

Cyanosis (can be observed by the nurse)

Petechiae (can be observed by the nurse)

So, the subjective data in this list is "Nausea." This is information that the client shares with the nurse about their symptoms or feelings.

The objective data includes A-"Blood pressure," B-"Cyanosis," and D-"Petechiae," which are findings that the nurse can measure or observe during the physical examination.

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A client with depression is admitted for voluntary treatment. While in the hospital, the client makes several comments about leaving the facility and kiling themselves with their gun. Which is the most appropriate action by the nurse when the client requests to leave against medical advice?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing several clients who have experienced loss. Which client will the nurse identify as experiencing complicated grieving? Select all that apply. (Select All that Apply.)

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

Explanation

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?

Correct Answer is C

Explanation

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