A nurse is caring for multiple clients on a mental health unit. Which of the following clients should the nurse attend to first?

A client in the dayroom who is screaming at other clients about what is on the television

A client who has bipolar disorder and is continuously pacing at the end of the hall

A client who is repeatedly approaching the nurses' station to request medication for their anxiety

A client who is standing in their room, yelling obscenities, and throwing their clothes

Answer and Explanation

The Correct Answer is D

A. A client in the dayroom who is screaming at other clients about what is on the television: This behavior is disruptive but does not pose an immediate safety threat to the client or others. The nurse should monitor and intervene as needed, but it is not the highest priority.

B. A client who has bipolar disorder and is continuously pacing at the end of the hall: Pacing may indicate agitation or restlessness, but if the client is not aggressive or threatening, it poses less immediate risk. The nurse should assess for escalation but prioritize clients with potentially dangerous behaviors first.

C. A client who is repeatedly approaching the nurses' station to request medication for their anxiety: While attention to anxiety is important, this behavior does not indicate imminent danger or risk of harm. It can be addressed after attending to clients who may be violent or unsafe.

D. A client who is standing in their room, yelling obscenities, and throwing their clothes: This client is exhibiting aggressive and potentially violent behavior that could escalate to self-harm or harm to others. Ensuring safety and de-escalation for this client takes priority over disruptive or non-threatening behaviors.

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

Explanation

A. Terminal liver cancer: Chronic or terminal illnesses can increase the risk of suicide due to pain, loss of independence, and feelings of hopelessness. Clients facing life-limiting conditions may experience emotional distress that contributes to suicidal ideation.

B. Sibling history of suicide: A family history of suicide is a known risk factor, as genetic predisposition and learned behaviors can increase vulnerability. Having a sibling who died by suicide elevates the client’s risk compared to the general population.

C. Access to guns in the home: Ready access to lethal means, such as firearms, significantly increases the risk of suicide. The presence of guns facilitates impulsive actions and higher fatality rates in suicide attempts.

D. Alcohol use disorder: Alcohol impairs judgment, increases impulsivity, and can exacerbate depression, all of which heighten suicide risk. Substance use disorders are commonly associated with suicidal behavior and attempts.

E. Currently married: Being married is generally considered a protective factor against suicide due to social support and connectedness. Marriage alone does not increase suicide risk and often decreases vulnerability compared to isolation or single status.

A. Prior head trauma B. High level of norepinephrine C. Serotonin deficiency D. Viral infections

Correct Answer is C

Explanation

A. Prior head trauma: While head trauma can contribute to cognitive changes or neurological deficits, it is not a primary risk factor for developing depressive disorders. It may increase vulnerability but is less directly associated than neurotransmitter imbalances.

B. High level of norepinephrine: Elevated norepinephrine is generally associated with hyperarousal or anxiety states, not depression. Depressive disorders are more commonly linked to deficiencies rather than excesses of certain neurotransmitters.

C. Serotonin deficiency: Low levels of serotonin are strongly implicated in the pathophysiology of depressive disorders. Serotonin regulates mood, sleep, and appetite, and a deficiency can contribute to symptoms such as low mood, anhedonia, and sleep disturbances.

D. Viral infections: While some infections can impact mood indirectly through inflammation or chronic illness, viral infections are not considered a direct risk factor for the development of depressive disorders. They may exacerbate existing depression but are not primary causes.

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A nurse is caring for multiple clients on a mental health unit. Which of the following clients should the nurse attend to first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

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Correct Answer is C

Explanation

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