A nurse in a mental health facility is assessing a client.

The client has a medical history of major depressive disorder for 20 years, anxiety disorder, suicide ideation during teenage years, and psychotherapy for the past 10 years with a therapist.

The client's mother committed suicide when the client was 25 years of age, and the father died of heart disease 10 years ago.

The client has a history of alcohol misuse, attended in-patient rehabilitation 4 years ago with no alcohol use since that time.

The nurse notes indicate good physical health with no reported morbidities.

For each client assessment finding, specify if the finding is a potential risk for suicide or a protective factor against suicide.

Mental health support

Family history

Physical health

Support systems

Alcohol consumption

Access to lethal means.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}

The correct answer/s is Choice/s.

Choice A rationale: Mental health support is generally considered a protective factor against suicide. Effective mental health care can help individuals manage their mental health conditions, which can reduce the risk of suicide.

Choice B rationale: Family history, particularly a family history of suicide, is a risk factor for suicide. The client’s mother’s suicide could potentially increase the client’s risk.

Choice C rationale: Good physical health is typically seen as a protective factor against suicide. Serious physical health conditions, including chronic pain, can increase suicide risk, but the client is reported to be in good physical health.

Choice D rationale: Support systems, such as feeling connected to family and community, are protective factors against suicide. They can provide emotional support and help individuals feel less isolated.

Choice E rationale: Alcohol consumption, especially misuse or addiction, is a risk factor for suicide. However, the client has attended rehabilitation and has not used alcohol for the past 4 years, which could be seen as a protective factor.

Choice F rationale: Access to lethal means is a risk factor for suicide. Limiting access to lethal means is a societal protective factor.

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Correct Answer is ["2"]

Explanation

The nurse should administer 2 tablets per dose.

Rationale:

Step 1: Determine the desired dose of diphenhydramine. The desired dose is 50 mg.

Step 2: Determine the available tablet strength. The available tablet strength is 25 mg.

Step 3: Divide the desired dose by the tablet strength to determine the number of tablets needed. 50 mg / 25 mg/tablet = 2 tablets

Therefore, the nurse should administer 2 tablets of diphenhydramine 25 mg per dose to achieve the desired dose of 50 mg.

A. Manifestations of seizure activity. B. Decreased urine output. C. Inability to recall events. D. Increase in white blood cell count.

Correct Answer is C

Explanation

Choice A rationale:

Manifestations of seizure activity are not a common adverse effect of clonazepam. In fact, clonazepam is often used to treat seizures. It is a benzodiazepine that works by decreasing abnormal electrical activity in the brain.

While it is possible for clonazepam to worsen seizures in some individuals, this is not a typical response. Therefore, it is not the most important adverse effect for the nurse to monitor.

Choice B rationale:

Decreased urine output is not a known adverse effect of clonazepam.

Some medications can affect kidney function and urine output, but clonazepam is not one of them. Therefore, it is not necessary for the nurse to monitor urine output in a client taking clonazepam. Choice C rationale:

Inability to recall events, also known as amnesia, is a common adverse effect of clonazepam.

Clonazepam can impair short-term memory, making it difficult for people to remember things that happened recently.

This can be a significant problem for clients who need to be able to recall important information, such as instructions from their healthcare providers.

Therefore, it is important for the nurse to monitor clients taking clonazepam for signs of amnesia.

Choice D rationale:

An increase in white blood cell count is not a known adverse effect of clonazepam. In fact, clonazepam can sometimes cause a decrease in white blood cell count.

However, this is a rare side effect and is not typically something that the nurse would need to monitor.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer diphenhydramine 50 mg PO every 6 hr to a client who has acute dystonia. The available medication is diphenhydramine 25 mg tablets. How many tablets should the nurse administer per dose?

Correct Answer is ["2"]

Explanation

A mental health nurse is planning care for a client who has a new prescription for clonazepam. For which of the following adverse effects should the nurse plan to monitor?

Correct Answer is C

Explanation

A nurse is providing a community health education class about suicide prevention.Which of the following should the nurse identify as risk factors for suicide? (Select all that apply).

A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions should be the nurse's highest priority?

A registered nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled "clonazepam". What is the nurse's first action?

A mental health nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect?

A provider prescribes quetiapine 50 mg PO divided equally every 12 hr for 3 days. Available is quetiapine 25 mg tablets. How many tablets should the nurse administer per dose on day 3? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is admitting a client to an alcohol abuse program. The client states, "I'm here because of my boss.It was part of my job to go to parties and drink with clients." The client's statement is an example of which of the following defense mechanisms?

A nurse is caring for a client who appears anxious following a recent tragedy.Which of the following statements by the client reflects an adaptive use of sublimation?

A nurse is planning care for a client who demonstrates manipulative behavior. Which of the following interventions should be included in the plan of care?