A nurse is caring for a client in an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?

Whether the client is financially incapable of paying for prescribed medications.

Whether the client is a danger to herself or others.

Whether the client is unable to make arrangements to stay with someone.

Whether the client is unwilling to accept that treatment is needed.

Answer and Explanation

The Correct Answer is B

Whether the client is a danger to herself or others. When a client is involuntarily admitted to a mental health unit, they are held for an initial period of 72 hours for evaluation and treatment. Afterward, a determination must be made as to whether or not the client is still a danger to themselves or others to keep them in the hospital.

Choices A, C, and D do not address the primary concern of ongoing safety for the client and others.

For choice A, the client's financial status or their ability to pay for prescribed medications is not relevant to their safety or need for hospitalization.

For choice C, the client's ability to make arrangements to stay with someone is important for discharge planning but not for determining their need for ongoing hospitalization.

Finally, for choice D, whether the client is unwilling to accept treatment is important, but not the sole determining factor as to whether they are a danger to themselves or others.

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Correct Answer is C

Explanation

"The client learns to change negative thoughts into positive statements." This demonstrates the effective use of cognitive reframing, which involves changing negative thoughts into positive self-talk. This strategy can help to reduce stress and improve coping skills.

Choice A, "The client imagines being in a quiet, relaxing environment," is not an example of cognitive reframing, but rather an example of visualization, which can also be useful in reducing stress.

Choice B, "The client trains his mind to relax by using deep inner resources," is not an example of cognitive reframing, but rather an example of relaxation training.

Choice D, "The client learns the source of his stress by writing down daily events," is not an example of cognitive reframing, but rather an example of stress management through self-reflection.

A. Determine triage level and examine and stabilize as needed. B. Give the patient information about facilities that specialize in treating people without health insurance. C. Ask the patient to sign in and provide method of payment for services. D. Transfer the patient to a hospital that specializes in traumatic brain injuries.

Correct Answer is A

Explanation

The nurse should determine the patient's triage level and examine and stabilize the patient as needed when caring for a patient without health insurance who is limping and dripping blood from a head wound in the Emergency department. This intervention is the priority because the patient could be at risk of life-threatening complications if their condition is left untreated. Giving the patient information about facilities that specialize in treating people without health insurance, choice B, and asking the patient to sign in and provide method of payment for services, choice C, may be necessary but are not the priority at this time. Transferring the patient to a hospital that specializes in traumatic brain injuries, choice D, may be necessary after stabilizing the patient, but it is not the priority at this time.

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A nurse is caring for a client in an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is helping a client relieve stress through cognitive reframing. Which of the following actions by the client demonstrates effective use of cognitive reframing?

Correct Answer is C

Explanation

A patient without health insurance comes into the Emergency department limping and dripping blood from a head wound. Which of the following should be done first for this patient?

Correct Answer is A

Explanation

A nurse on an acute care mental health unit is caring for a client who has generalized anxiety disorder. The client received an upsetting telephone call and is now rapidly pacing the corridors of the unit. Which of the following actions should the nurse take?

A nurse is collecting data on a client who is experiencing chronic stress. Which of the following is an expected finding?

A nurse is collecting data from a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse should realize that the client's repetitive behaviors occur due to which of the following?

An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or four times a day. I get angry because I think that the client might be doing it just to get attention." Which of the following responses by the nurse is therapeutic?

A nurse is reinforcing teaching about alcohol withdrawal with a client who has a history of alcohol use disorder. Which of the following client statements indicates an understanding of the teaching?

The home health nurse visits a patient with a diagnosis of type 1 diabetes mellitus. The patient reports a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the patient indicates a need for further teaching?

A nurse in a community clinic is speaking to other nurses about risk factors for domestic violence. Which of the following statements by one of the other nurses indicates the need for further teaching?

A nurse is assisting with the admission of a client to an acute mental health unit following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions should the nurse take first?