A nurse is caring for a client:

The client has returned to work at an accounting firm and has started going to a grief support group. She reports she is seeking care from a healthcare professional because her father is worried about her. The client says she only gets 2 to 3 hours of sleep due to nightmares about the crash. She informs that exercising right after work helps her get better sleep and to relax. She feels that she is "jumpy" after the accident, especially when she is in the car. She also stated, "I feel so sad that I can't seem to feel anything at all." In addition to her father, the client has a large family and friend support system. She denies alcohol or drug use.

Click to highlight the areas that the nurse should react to immediately. The client has returned to work at an accounting firm and has started going to a grief support group. She reports she is seeking care from a healthcare professional because her father is worried about her. The client says she only gets 2 to 3 hours of sleep due to nightmares about the crash. She informs that exercising right after work helps her get better sleep and to relax. She feels that she is "jumpy" after the accident, especially when she is in the car. She also stated, "I feel so sad that I can't seem to feel anything at all" In addition to her father, the client has a large family and friend support system. She denies alcohol or drug use.

she only gets 2 to 3 hours of sleep

She feels that she is "jumpy" after the accident

I feel so sad that I can't seem to feel anything at all"

The client has returned to work at an accounting firm

Answer and Explanation

The Correct Answer is ["A","B","C"]

In the scenario presented, the nurse should prioritize addressing the client's sleep disturbances, heightened startle response, and feelings of sadness and numbness. These symptoms may indicate acute stress reaction or post-traumatic stress disorder, conditions that can occur after experiencing a traumatic event such as a car crash. Immediate interventions could include providing a safe and calm environment, offering support and reassurance, assessing for risk of harm to self or others, and referring to mental health professionals for further evaluation and treatment. It's also important to acknowledge the client's proactive steps, such as joining a grief support group and exercising, which are positive coping strategies. The nurse should collaborate with the client to build on these healthy habits while addressing the more distressing symptoms with appropriate care and referrals.

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Correct Answer is B

Explanation

A. This comment may come across as invalidating the client's feelings by assuming overreaction, which could potentially escalate the situation.
B. This response acknowledges the client's feelings and invites further exploration, fostering a therapeutic relationship and understanding of the client's experiences.
C. While understanding the cause of symptoms is important, it may not necessarily make them easier to handle, and it could divert focus from addressing the client's immediate concerns.
D. While encouragement is positive, this comment does not directly address the client's feelings or concerns, which is essential for building a therapeutic relationship.

A. A retired older male whose significant other has passed away. B. A nurse who works in a pediatric emergency department. C. An adolescent male whose parents recently divorced. D. A single working mother with three pre-school aged children.

Correct Answer is C

Explanation

A. While the loss of a significant other can be a risk factor for suicide, retired older males may have developed coping mechanisms over time that could mitigate the risk.
B. While working in a pediatric emergency department can be stressful, it does not necessarily indicate a higher risk for suicide compared to other factors such as personal life stressors or mental health issues.
C. Adolescents experiencing significant life changes such as parental divorce are at increased risk for suicide due to the emotional upheaval and lack of coping skills typical of this age group.

D. While being a single working mother with three preschool-aged children can be stressful, it does not inherently indicate a higher risk for suicide compared to other factors such as social support, coping mechanisms, and mental health status.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the mental health unit with a bipolar disorder. When seeking to establish a therapeutic relationship and interacting with the client, which comment is best for the nurse to make?

Correct Answer is B

Explanation

Which individual should the nurse consider at highest risk for suicide?

Correct Answer is C

Explanation

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

The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?

An adult female client is brought to the Emergency Center after fainting at work. The nurse completes an assessment of the client and identifies caregiver role strain as a nursing problem. Which information best supports this problem?

Which intervention(s) should the nurse include in the plan of care for an adolescent client who is depressed? Select all that apply.

The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessment?

A male client with a recent diagnosis of bipolar disorder takes lithium carbonate daily. The client informed the school nurse of the desire to live away from home to attend college after graduating in one month. Which information is most important for the nurse to provide the client and his family?

A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?