A nurse is caring for a client three days after admission for treatment of depression. The client leaves her current activity, approaches the nurse, and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take?

Ask the client if she has a plan to commit suicide.

Assist the client to her room and allow her to rest before resuming activity.

Recognize the attempt at manipulation and escort the client back to her activity.

Notify the client's family and request a visitor to stay with the client until thoughts of suicide are gone.

Answer and Explanation

The Correct Answer is A

Choice A reason:
When a client expresses thoughts of wanting to end their life, it is crucial for the nurse to immediately assess the risk of suicide. Asking the client if they have a plan to commit suicide is a direct approach to gauge the immediacy and seriousness of the risk. This information is vital for determining the next steps in care, which may include close supervision, safety precautions, and urgent psychiatric evaluation.

Choice B reason:
While ensuring the client is comfortable is important, allowing the client to rest without further assessment or intervention may not be safe if the client is at immediate risk of self-harm. The priority is to assess and secure the client's safety.

Choice C reason:
It is inappropriate and potentially dangerous to dismiss the client's statement as manipulation. All expressions of suicidal ideation should be taken seriously, and the nurse should provide a supportive response that addresses the client's emotional state and safety concerns.

Choice D reason:
Notifying the client's family can be part of a broader safety plan, but it should not replace immediate assessment and intervention by the healthcare team. Family members may provide support, but they are not a substitute for professional care and suicide risk assessment.

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Correct Answer is C

Explanation

Choice A reason:
Escorting the client to the common area is not the priority action. While being around others can sometimes be comforting, during a panic attack, the client may feel overwhelmed and exposed, which could exacerbate the situation.

Choice B reason:
Contacting security for possible restraints should be a last resort and is not the priority action. Restraints can increase anxiety and fear, potentially escalating the panic attack. The use of restraints is only considered when the client is at risk of harming themselves or others and all other interventions have failed.

Choice C reason:
Staying with the client is the priority action. During a panic attack, the client needs reassurance and a sense of safety. The nurse's presence can provide comfort. The nurse should remain calm, use a quiet voice, and avoid making any sudden movements. Implementing relaxation techniques and promoting a calming environment are also beneficial.

Choice D reason:
Staying away from the client is not the priority action. Leaving the client alone can increase feelings of isolation and fear. The nurse should provide continuous observation and support during the panic attack.

A. "It may take up to at least 2 weeks to see the effects of bupropion." B. "I can drink one glass of wine with dinner each day while taking bupropion." C. "I may develop a slow heartbeat while taking bupropion." D. "I should watch for increased salivation and drooling while taking bupropion."

Correct Answer is A

Explanation

Choice A reason:
This statement is accurate and reflects effective teaching. Bupropion, like many antidepressants, can take several weeks to reach its full therapeutic effect. Informing patients about this delay is important to set realistic expectations and to encourage adherence to the medication regimen.

Choice B reason:
This statement is not entirely accurate. While moderate alcohol consumption may be permissible for some patients taking bupropion, it is generally advised to avoid or limit alcohol intake due to the risk of seizures and other side effects. Alcohol can also worsen depression symptoms and interact with the medication.

Choice C reason:
This statement is incorrect. Bupropion does not typically cause bradycardia (slow heartbeat). Instead, it can cause tachycardia (fast heartbeat) as a side effect. Patients should be informed about the potential cardiovascular effects of bupropion, including an increased heart rate.

Choice D reason:
This statement is incorrect. Increased salivation and drooling are not common side effects of bupropion. The medication is more commonly associated with dry mouth. Effective teaching would include informing the patient about the more likely side effects, such as dry mouth, insomnia, and headaches.

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A nurse is caring for a client three days after admission for treatment of depression. The client leaves her current activity, approaches the nurse, and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with generalized anxiety disorder who is experiencing a panic attack. Which of the following is the nurse's priority action for this client?

Correct Answer is C

Explanation

The nurse is evaluating teaching for a client diagnosed with depression who is prescribed bupropion (Wellbutrin). Which of the following statements made by the client indicates that the teaching was effective?

Correct Answer is A

Explanation

A nurse is caring for a client who has been taking Xanax (alprazolam) for anxiety. The nurse anticipates which of the following?

A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?

A nurse is caring for a client who is withdrawing from a stimulant. Which of the following should be prioritized for safety in a client with stimulant withdrawal?

A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?

A nurse on a crisis hotline is speaking to a client who says, "I just took an entire bottle of amitriptyline." Which of the following responses should the nurse make?

A nurse is providing discharge teaching to a client diagnosed with bipolar disorder who will be discharged with a prescription for lithium. The nurse should teach the client that which of the following is a risk factor for lithium toxicity?

Serotonin-norepinephrine reuptake inhibitors (SNRIs), such as Duloxetine, are used for generalized anxiety disorder. Which of the following increases the risk for the client developing serotonin syndrome?

A client commits suicide in an acute mental health facility. Which of the following is the priority intervention for staff on the unit as a follow-up to this incident?