A homeless female client who reports feeling sad and depressed tells the mental health nurse that in the past two days, the client has only had four hours of sleep. Which action is most important for the nurse to implement within the first 24 hours after treatment is initiated?

Allow the client to rest and sleep.

Begin planning for the client’s discharge.

Encourage verbalization of feelings.

Ensure the client attends groups addressing coping skills for dealing with depression.

Answer and Explanation

The Correct Answer is A

A.   Allowing the client to rest and sleep is a priority, as sleep deprivation can exacerbate symptoms of depression. Addressing immediate physical needs is crucial.
B.   Planning for discharge can be addressed later in the treatment process; the immediate focus should be on ensuring the client's basic needs are met.
C. Encouraging verbalization of feelings is important but should not take precedence over addressing the client's sleep deprivation.
D.   Ensuring the client attends groups addressing coping skills for dealing with depression is valuable but may be addressed after the client has had sufficient rest. Prioritizing sleep helps address the most immediate concern.

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Correct Answer is D

Explanation

A. The healthcare provider's history and physical may provide information about the client's overall health but may not specifically address the observed symptoms.
B. Recent urine drug testing (UDT) results may reveal drug use but may not be directly related to the observed involuntary movements.
C. The baseline nursing admission assessment may provide general information but may not specifically address medication side effects.
D. The Abnormal Involuntary Movement Scale (AIMS) is specifically designed to assess and document involuntary movements associated with psychotropic medications, making it the most relevant assessment tool in this situation.

A. Request a team member to assist with seclusion and restraint. B. Administer lorazepam 1.5 mg intramuscularly twice daily as needed. C. Confirm the client’s identity and orientation to time and place. D. Inspect the area for objects that can be used in a dangerous manner. E. None F. None

Correct Answer is D

Explanation

Rationale for A: While seclusion and restraint may be necessary, this should be considered after assessing the environment for immediate safety concerns.

Rationale for B: Administering medication may help calm the client but does not address immediate safety concerns.

Rationale for C: Confirm the client’s identity and orientation to time and place is a therapeutic intervention that helps ground the client during a dissociative episode. However, in a situation where physical aggression is present, ensuring safety takes precedence over reorientation.

Rationale for D. Inspect the area for objects that can be used in a dangerous manner is the first and most critical action. When a client becomes physically aggressive, the nurse's priority is to maintain safety for the client, staff, and others in the environment. Removing or securing potentially harmful objects minimizes the risk of injury and creates a safer setting for subsequent interventions.

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A homeless female client who reports feeling sad and depressed tells the mental health nurse that in the past two days, the client has only had four hours of sleep. Which action is most important for the nurse to implement within the first 24 hours after treatment is initiated?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client’s record should the nurse review?

Correct Answer is D

Explanation

A client with post-traumatic stress disorder (PTSD) is experiencing a dissociative disorder episode. The situation quickly escalates, and the client becomes physically aggressive. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the client’s history should the nurse further explore?

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