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 D

Explanation

"I know you will do well living out in the community.". When a client expresses feelings of gratitude towards a nurse as they are about to be discharged, they are mostly affirming the therapeutic relationship between both parties. The nurse should acknowledge this affirmation clearly, warmly, and humbly, while encouraging the client's progress and independence. Choice D, "I know you will do well living out in the community" acknowledges the client's progress and offers encouragement.

Choice A, "Aren't you excited about being discharged today?" is a closed question that does not encourage the client's progress.

Choice B, "How do you feel about being discharged?" is not the best response because it is too broad.

Choice C, "I will send you a note in a few weeks" does not offer affirmation and encouragement to the client.

A. Remind the client that if her weight decreases, she will lose a privilege. B. Allow the client to exercise once per day for a set amount of time. C. Ask the client why she feels the need to exercise so often. D. Allow the client to exercise when she wants as long as she eats 50% of all meals.

Correct Answer is B

Explanation

Allow the client to exercise once per day for a set amount of time. It is important to set limits and boundaries for a client with anorexia nervosa to ensure their safety, but also to respect their autonomy.

Reminding the client of weight loss consequences (choice A) can be counterproductive, asking why they exercise frequently (choice C) is important, but not sufficient without setting boundaries, and allowing the client to exercise as long as they eat 50% of their meals (choice D) can be dangerous.

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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 caring for a client with whom he has developed a therapeutic relationship and who will be discharged later in the day. The client thanks the nurse for his help during the hospitalization. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is caring for a client who has anorexia nervosa and insists on exercising three times each day. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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?

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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?

A nurse is caring for a patient with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, by which of the following times should the nurse ensure the patient receives breakfast?

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A nurse is caring for a patient who is undergoing initial peritoneal dialysis. Which of the following should the nurse report immediately to the provider?

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 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?