A nurse is caring for a client three days after admission to an acute care mental health facility for treatment of major 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 nursing interventions is appropriate?

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

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

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

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

Answer and Explanation

The Correct Answer is A

Choice A reason: Directly asking the client about suicidal plans is a critical step in assessing risk and determining the need for immediate intervention.

Choice B reason: While involving the family is important, it does not address the immediate risk the client may pose to herself.

Choice C reason: Recognizing the statement as a manipulation attempt is inappropriate; all expressions of suicidal ideation should be taken seriously.

Choice D reason: Allowing the client to rest does not address the immediate risk of suicide and the need for urgent assessment and intervention.

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Naxlex Comprehensive Predictor Exams

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

Explanation

Choice A reason: Reducing saturated fats, which are found primarily in red meat and full-fat dairy products, can lower low-density lipoprotein (LDL) cholesterol — the "bad" cholesterol.

Choice B reason: Avoiding trans fats is crucial as they increase LDL cholesterol and decrease high-density lipoprotein (HDL) cholesterol — the "good" cholesterol.

Choice C reason: Consuming whole grains is beneficial for lowering cholesterol because they contain soluble fiber, which can reduce the absorption of cholesterol into the bloodstream⁶.

Choice D reason: Limiting sugar-sweetened beverages can help reduce cholesterol levels, as excessive sugar intake can lead to weight gain, which is a risk factor for high cholesterol.

Choice E reason: Drinking whole milk is not recommended for cholesterol control as it contains high levels of saturated fat, which can raise cholesterol levels.

Choice F reason: Limiting fruit intake is not necessary for cholesterol control; in fact, fruits can be beneficial due to their fiber content⁶.

A. Have the patient sit in his room while you review all the rules of the unit. B. Reinforce previously learned coping mechanisms to calm the patient down. C. Place the patient in a room with another hyperactive patient. D. Administer antipsychotic medication as ordered and as needed by the physician.

Correct Answer is D

Explanation

Choice A reason: Having the patient sit alone while reviewing rules does not address the immediate risk of injury due to hyperactivity.

Choice B reason: Reinforcing coping mechanisms can help the patient manage hyperactivity and reduce the risk of injury.

Choice C reason: Placing the patient with another hyperactive patient could potentially exacerbate the situation and increase the risk of injury.

Choice D reason: While administering medication may be necessary, it should be done in conjunction with other interventions that address behavior management.

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Naxlex Comprehensive Predictor Exams

The nurse is reinforcing teaching to the patient about controlling cholesterol with diet. Which of the following dietary actions help reduce cholesterol? Select all that apply.

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

Explanation

A newly admitted patient in an acute manic state has a nursing diagnosis of at risk for injury related to hyperactivity. Which nursing intervention is most appropriate?

Correct Answer is D

Explanation

A nurse is collecting data from an older adult client who has been taking digoxin for the past several months. For which of the following manifestations of digoxin toxicity should the nurse monitor?

The nursing interventions for a patient with major depression would include all the following except:

The licensed practical nurse is assisting with collecting data on a female patient. Which of the following findings should be reported to the registered nurse as possible atypical symptoms of a myocardial infarction in the absence of chest pain? Select all that apply.

A nurse is collecting data from a client who has bipolar disorder with mania. Which of the following findings is the nurse's priority?

A patient hospitalized with a myocardial infarction suddenly begins having severe respiratory distress with frothy red sputum. What is the first action for the nurse to take?

The nurse is reinforcing teaching to the patient about the cause of pain from coronary artery disease. The nurse would evaluate the patient as understanding the education if the patient stated which of the following causes the pain from coronary artery disease?

A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects?

Your patient with major depressive disorder isolates herself in her room for the whole day. You find her sitting and staring out the window. What is your best therapeutic response when you walk into her room?