A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

Identify support groups in the community for long-term treatment.

Assist the client to identify negative effects of chemical dependency.

Determine the presence and degree of suicidal risk.

Refer client to mental health care provider for evaluation and treatment.

Answer and Explanation

The Correct Answer is C

The nurse should determine the presence and degree of suicidal risk when caring for a client who has a depressive disorder, is in alcohol withdrawal, and reports a recent job loss. This intervention is the priority because the client is at increased risk of suicidal ideation or behavior due to the combination of depression, alcohol withdrawal, and recent job loss. Identifying support groups in the community for long-term treatment.

choice A and referring the client to a mental health care provider for evaluation and treatment.

choice D are important interventions but are not the priority at this time. Assisting the client to identify the negative effects of chemical dependency.

choice B may be necessary but does not address the priority concern of suicidal risk.

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Correct Answer is A

Explanation

The nurse should determine the patient's triage level and examine and stabilize the patient as needed when caring for a patient without health insurance who is limping and dripping blood from a head wound in the Emergency department. This intervention is the priority because the patient could be at risk of life-threatening complications if their condition is left untreated. Giving the patient information about facilities that specialize in treating people without health insurance, choice B, and asking the patient to sign in and provide method of payment for services, choice C, may be necessary but are not the priority at this time. Transferring the patient to a hospital that specializes in traumatic brain injuries, choice D, may be necessary after stabilizing the patient, but it is not the priority at this time.

A. The client pretends to be a government agent. B. The client reports seeing bugs crawling on the walls. C. The client describes an increase in pain after receiving meperidine. D. The client reports his heart is beating out of his chest.

Correct Answer is D

Explanation

"The client reports his heart is beating out of his chest." as this symptom is consistent with anxiety and the client's prescription is for PRN anxiety. Alprazolam is a medication used to treat anxiety disorders and symptoms of anxiety.

Choice A, "The client pretends to be a government agent," is not a symptom that would be treated with alprazolam.

Choice B, "The client reports seeing bugs crawling on the walls," may indicate the presence of a hallucination or other mental health symptom, but is not related to anxiety and is not an appropriate indication for alprazolam.

Choice C, "The client describes an increase in pain after receiving meperidine," indicates a potential adverse drug effect and is not related to anxiety or an indication for alprazolam.

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A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient without health insurance comes into the Emergency department limping and dripping blood from a head wound. Which of the following should be done first for this patient?

Correct Answer is A

Explanation

A nurse is caring for a client who has a prescription for alprazolam 0.25 mg PO every 8 hr PRN anxiety. For which of the following situations should the nurse administer the alprazolam?

Correct Answer is D

Explanation

A nurse on an acute care mental health unit is caring for a client who has generalized anxiety disorder. The client received an upsetting telephone call and is now rapidly pacing the corridors of the unit. Which of the following actions should the nurse take?

A nurse is caring for a client who has an alcohol use disorder and is experiencing withdrawal. Which of the following interventions is the nurse's priority?

An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or four times a day. I get angry because I think that the client might be doing it just to get attention." Which of the following responses by the nurse is therapeutic?

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?

A nurse is discussing the reporting of child abuse with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A nurse is collecting data from a female client who has anorexia nervosa. Which of the following findings should the nurse expect?

A nurse is helping a client relieve stress through cognitive reframing. Which of the following actions by the client demonstrates effective use of cognitive reframing?

A nurse is caring for a 20-year-old college student who has a 2-year history of bulimia nervosa. She tells the nurse, "I know my eating binges and vomiting are not normal, but I cannot do anything about them." Which of the following is a therapeutic response by the nurse?