A nurse on an acute mental health unit is caring for a group of clients. For which of the following clients is seclusion contraindicated?

A school-age client who attempts to repeatedly bite staff.

An older adult client who is manic and agitated due to overstimulation.

An adolescent client who throws objects at other clients.

An adult client after an interrupted suicide attempt.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Seclusion may be considered for a school-age client who repeatedly bites staff as a method of last resort to ensure the safety of both the client and staff.

It's important to exhaust other interventions first, such as verbal de-escalation, redirection, and medication.

If seclusion is used, it should be implemented under strict guidelines, with close monitoring and frequent reassessment to determine its effectiveness and necessity.

Choice B rationale:

Seclusion may be considered for an older adult client who is manic and agitated due to overstimulation, as it can provide a safe and quiet environment to reduce sensory input and promote calming.

However, it's crucial to carefully assess the client's physical and cognitive status, as seclusion can exacerbate confusion and disorientation in older adults.

Close monitoring and reassessment are essential.

Choice C rationale:

Seclusion may be considered for an adolescent client who throws objects at other clients to maintain safety and prevent harm to others.

It's important to first attempt other interventions, such as verbal de-escalation, redirection, and limit-setting.

If seclusion is used, it should be brief and implemented with therapeutic goals in mind, such as promoting self-regulation and problem-solving skills.

Choice D rationale:

Seclusion is contraindicated for an adult client after an interrupted suicide attempt.

This is because seclusion can increase isolation, hopelessness, and despair, which are significant risk factors for suicide.

It can also hinder close observation and monitoring of the client's mental state, potentially leading to further suicide attempts.

Instead, the focus should be on providing supportive, one-to-one contact, ensuring safety, and establishing therapeutic rapport to address the underlying issues that led to the suicide attempt.

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Correct Answer is B

Explanation

Choice A rationale: Providing privacy when friends visit is a general good practice in nursing. However, it may not be the most effective intervention for a client with anorexia nervosa. Anorexia nervosa is characterized by a distorted body image and an intense fear of gaining weight. While privacy is important, it is not directly related to the management of anorexia nervosa.

Choice B rationale: Scheduling regular weigh-in times is a key intervention for clients with anorexia nervosa. Regular weigh-ins help monitor the client’s progress and any potential complications related to weight loss. This intervention is directly related to the management of anorexia nervosa and is therefore the correct answer.

Choice C rationale: Complimenting the client for weight gain can be a sensitive issue for individuals with anorexia nervosa. While it might seem like a positive reinforcement, it could potentially trigger anxiety and fear in the client, as individuals with anorexia nervosa have an intense fear of gaining weight. Therefore, this intervention should be handled with care and is not the best choice in this scenario.

Choice D rationale: Allowing the client to eat at any time might seem like a good idea, but it is not the most effective intervention for a client with anorexia nervosa. Individuals with anorexia nervosa often have strict rituals and rules around eating. Allowing them to eat at any time might not address these underlying issues and could potentially enable their disordered eating habits.

A. "My arms often feel weak and spastic." B. "I check where my car keys are ten times." C. "I'm embarrassed to go out and speak in public." D. "I keep reliving a car accident almost every day.".

Correct Answer is B

Explanation

Choice A rationale: The statement “My arms often feel weak and spastic” does not indicate obsessive-compulsive disorder (OCD). This could be a symptom of a physical condition or a different mental health disorder, but it does not align with the common symptoms of OCD. OCD is characterized by unwanted, recurring thoughts and repetitive behaviors.

Choice B rationale: The statement “I check where my car keys are ten times” is indicative of OCD. One of the key symptoms of OCD is the need to check things repeatedly due to persistent, unwanted thoughts and fears. The individual may check something over and over again, such as whether the door is locked or where their car keys are, even if they know they’ve already checked. This behavior is a compulsion - an act the person feels compelled to perform to alleviate the distress caused by the obsessive thought.

Choice C rationale: The statement “I’m embarrassed to go out and speak in public” could be indicative of social anxiety disorder, not OCD. Social anxiety disorder is characterized by a fear of social situations and interactions, particularly those involving the possibility of scrutiny or judgment by others. While people with OCD can also have social anxiety disorder, embarrassment about going out and speaking in public is not a typical symptom of OCD12.

Choice D rationale: The statement “I keep reliving a car accident almost every day” is more indicative of post- traumatic stress disorder (PTSD) than OCD. PTSD is a mental health disorder that can develop after experiencing or witnessing a traumatic event, such as a car accident. Symptoms of PTSD include flashbacks, nightmares, and severe anxiety, as well as uncontrollable thoughts about the event. While people with OCD can have intrusive thoughts, these thoughts are typically related to themes like contamination or orderliness, rather than reliving past traumas.

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A nurse on an acute mental health unit is caring for a group of clients. For which of the following clients is seclusion contraindicated?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a client who has anorexia nervosa. Which of the following nursing interventions should the nurse take?

Correct Answer is B

Explanation

A psychiatric nurse assesses a client who commonly experiences anxiety.Which comment by this person indicates the possibility of obsessive-compulsive disorder (OCD)?

Correct Answer is B

Explanation

A nurse is caring for a client who has major depressive disorder and attempted suicide.The client tells the nurse, "I should have died because I am totally worthless." Which of the following responses should the nurse make?

A mental health nurse is assessing a client who reports an increase in anxiety. Which of the following responses should the nurse make?

A mental health nurse is reviewing the medical record of a client who self-harms. Which of the following pieces of information should the nurse identify as placing the client at risk for self-harm behaviors?

A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions should be the nurse's highest priority?

A nurse is planning discharge for a client who has borderline personality disorder. Which of the following interventions should be included for this client?

A nurse is preparing to administer clozapine 300 mg PO daily to a client who has schizophrenia. The amount available is clozapine 200 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies.Do not use a trailing zero.).

A nurse is preparing to administer amantadine 150 mg PO every 12 hr. The available medication is amantadine 50 mg/5 mL syrup. How many mL should the nurse administer per dose?

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