A male client, assessed in the emergency department (ED), has a strong odor of alcohol on his breath. The client denies thoughts of harm to self or others, and the healthcare provider discharges the client. As the client begins to leave, the nurse overhears the client mumble, “Now I’m going to shoot myself.” Which intervention should the nurse implement?

Inquire about the client’s support system.

Ask the client to repeat his comment.

Stop the client from leaving the ED.

Record the statement in the client’s chart.

Answer and Explanation

The Correct Answer is C

A.   Inquiring about the client’s support system may be important, but the immediate concern is the statement indicating a potential risk of harm.
B.   Asking the client to repeat the comment may not be as effective as taking immediate action to prevent harm.
C. Stopping the client from leaving the ED is the priority to ensure the client's safety and prevent the potential act of self-harm.
D.   Recording the statement in the client's chart is important but should be done after taking immediate action to address the potential risk.

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Correct Answer is C

Explanation

A. A family history of dementia may be relevant but is not typically associated with violent nightmares. Alcohol use is more directly related to this symptom.
B. Witness to an accident may be a traumatic experience, but it does not specifically address the symptom of violent nightmares.
C. Alcohol use can contribute to sleep disturbances, including nightmares. Exploring the client's alcohol use is essential in understanding the cause of the nightmares.
D. Inadequate diversional activity is a broad concept and may not be directly related to the specific symptom of violent nightmares.

A. Inquire about the client’s support system. B. Ask the client to repeat his comment. C. Stop the client from leaving the ED. D. Record the statement in the client’s chart.

Correct Answer is C

Explanation

A. Inquiring about the client’s support system may be important, but the immediate concern is the statement indicating a potential risk of harm.
B. Asking the client to repeat the comment may not be as effective as taking immediate action to prevent harm.
C. Stopping the client from leaving the ED is the priority to ensure the client's safety and prevent the potential act of self-harm.
D. Recording the statement in the client's chart is important but should be done after taking immediate action to address the potential risk.

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is C

Explanation

Correct Answer is C

Explanation

A client at the mental health center reports difficulty concentrating at work, feeling very tired during the day, and sleeping 4 to 5 hours at night. To further assess for depression, which question is most important for the nurse to ask?

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?

The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?

The nurse completes an assessment of a client experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?

An older man with a history of multiple falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become increasingly abusive since his release from prison six weeks ago. Which intervention is most important for the nurse to implement?

A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. Which action should the nurse implement first?

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?