A nurse is caring for a client who has depression and states, "A government agency is attempting to capture me." The nurse should identify that the client is experiencing which of the following?

Inappropriate guilt

Mania

Delusions

Confusion

Answer and Explanation

The Correct Answer is C

A. Inappropriate guilt is a common symptom of depression, but it does not involve false beliefs about being targeted. Clients with major depressive disorder may feel excessive guilt, but this differs from the fixed, false beliefs seen in delusions.
B. Mania is characterized by elevated mood, impulsivity, and hyperactivity rather than paranoid thoughts. While manic episodes may include grandiose delusions, the belief that a government agency is attempting to capture the client aligns more with persecutory delusions.
C. Delusions are fixed, false beliefs that persist despite evidence to the contrary. The client’s statement suggests a persecutory delusion, which is commonly seen in psychotic disorders, including severe depression with psychotic features.
D. Confusion involves disorganized thinking, memory impairment, or difficulty understanding surroundings, often seen in delirium or cognitive disorders. While delusions can contribute to disorganized thoughts, they are distinct from general confusion.

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Correct Answer is ["C","D","E"]

Explanation

A. Nylon socks. Nylon socks do not pose a significant risk for self-harm and can be safely kept with the client. They are not considered a ligature risk or a hazardous object.
B. Cotton underwear. Cotton underwear is not a safety concern in a mental health unit. It does not present a strangulation risk or any other immediate danger.
C. Lace-up tennis shoes. Lace-up shoes contain long laces that could be used as a ligature, posing a strangulation risk. Clients in a mental health unit are typically provided with slip-on or Velcro shoes to enhance safety.
D. Glass-framed picture of the client's partner. A glass frame poses a significant risk as it can be broken and used as a sharp object for self-harm. The nurse should ask the partner to take it home or provide a safer alternative, such as a laminated photo.
E. Necklace. A necklace can be used for strangulation, making it unsafe for a client at risk of self-harm. Removing items that could be used for ligature or harm is essential in suicide prevention.

A. When attending dialectical behavior therapy B. When getting married C. When discharged from the hospital D. When attending narrative therapy

Correct Answer is C

Explanation

A. "When attending dialectical behavior therapy." Dialectical behavior therapy (DBT) is specifically designed to help individuals with borderline personality disorder (BPD) manage emotions and reduce self-harming behaviors. While therapy can bring up distressing emotions, it provides structured support and coping strategies. The risk of self-harm is lower when clients are actively engaged in treatment and receiving professional guidance.
B. "When getting married." Major life changes, including marriage, can be stressful for individuals with BPD, but they do not inherently pose the highest risk for self-harm. Support from a partner and structured therapy can help navigate emotional challenges. While instability in relationships can trigger distress, the protective factors of marriage may reduce immediate risk. Self-harm risk is typically higher in periods of transition without support.
C. "When discharged from the hospital." Clients with BPD often struggle with emotional regulation, and discharge represents a significant transition with decreased support. The sudden loss of a structured inpatient setting can increase feelings of abandonment and distress, leading to a heightened risk of self-harm. Ensuring a follow-up care plan and support system is crucial to reducing this risk after hospitalization.
D. "When attending narrative therapy." Narrative therapy helps clients reframe their experiences and build a stronger sense of identity. Although deep emotional topics may be explored, structured therapy provides a safe space for expression. Therapeutic interventions aim to reduce distress and teach coping mechanisms, decreasing the likelihood of self-harm. The highest risk occurs when structured support is suddenly removed.

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A nurse is caring for a client who has depression and states, "A government agency is attempting to capture me." The nurse should identify that the client is experiencing which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on an acute care mental health unit is examining the belongings of a client who is being admitted following a suicide attempt. Which of the following belongings should the nurse ask the client's partner take back home? (Select All that Apply.)

Correct Answer is ["C","D","E"]

Explanation

A nurse is discussing borderline personality disorder and the risk for self-harm with a newly licensed nurse. Which of the following situations should the nurse identify as the highest risk for self-harm?

Correct Answer is C

Explanation

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