A nurse on a mental health unit is planning care for a client who has a new diagnosis of non- suicidal self-harm (NSSH). Which of the following interventions should the nurse include in the plan?

Explain to the client that self-harm behaviors do not increase their risk for accidental death.

Inform the client that self-harm behavior cannot become a serious problem in the future.

Encourage the client to identify the emotions they feel immediately before performing the self- harm behavior.

Place the client in one-on-one direct observation due to overt suicidal intent.

Answer and Explanation

The Correct Answer is C

C Encouraging the client to identify the emotions they feel immediately before performing the self-harm behavior is an important intervention. It can help the client develop insight into triggers and underlying emotions that contribute to the behavior. Identifying and addressing these emotions can be a crucial step in developing healthier coping mechanisms.

A. It is crucial to convey the potential risks associated with self-harm and emphasize the importance of seeking help and safer coping strategies.

B. Non-suicidal self-harm is a significant concern that requires attention and appropriate intervention. While NSSH does not necessarily indicate immediate suicidal intent, it can indicate significant distress

D. NSSH does not necessarily indicate suicidal intent, and placing the client in constant observation without clinical justification may be intrusive and undermine therapeutic rapport.

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Correct Answer is A

Explanation

A. Phase 1 of the cycle of violence, also known as the tension-building phase, is characterized by increasing tension and conflict between the parties involved in the abusive relationship. During this phase, arguments, disagreements, and conflicts escalate in frequency and intensity.

B Physical harm typically occurs during phase 2 of the cycle of violence, known as the acute or explosion phase.

C. This phase follows the acute phase and is characterized by the perpetrator expressing remorse, making excuses for their behavior, or attempting to reconcile with the victim through gestures of affection, gifts, or promises to change. However, these promises are often short- lived and may be followed by a return to tension-building behavior and the cycle of violence repeating.

D. Law enforcement involvement is not specific to phase 1 of the cycle, during which tensions are escalating and conflicts are increasing in frequency.

A. The importance of routine red blood cell count laboratory work when taking an antipsychotic B. The importance of limiting fluid intake when taking an antipsychotic C. The importance of avoiding foods that contain tyramine when taking an antipsychotic D. The importance of medication adherence after the resolution of acute psychosis when taking an antipsychotic

Correct Answer is D

Explanation

A. One of the most significant potential side effects of clozapine is agranulocytosis, a severe decrease in the number of white blood cells not red blood cells, particularly neutrophils.

B. Limiting fluid intake is not typically a specific concern associated with clozapine.

C. Clozapine is not known to have significant interactions with tyramine-rich foods

D. Medication adherence is a key component in clients on clozapine to prevent acute psychotic episodes.

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A nurse on a mental health unit is planning care for a client who has a new diagnosis of non- suicidal self-harm (NSSH). Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is presenting an in-service about the cycle of violence to nursing staff. The nurse should include that which of the following occurs during phase 1 of the cycle of violence?

Correct Answer is A

Explanation

A nurse is caring for a client who has been prescribed clozapine. Which of the following topics should the nurse prepare to discuss with the client?

Correct Answer is D

Explanation

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