A young-adult client is admitted to the psychiatric unit because of a recent suicide attempt. The client's spouse filled for divorce six months ago, the client lost a job three months ago, and the best friend moved to another city two weeks ago. Which intervention should the nurse include in this client's plan of care?

Allow the client time alone to sort out any feelings.

Avoid discussing subjects that upset the client.

Encourage activities that allow the client to exert control over the client's environment.

Encourage the client to interact with persons who are recovering from depression.

Answer and Explanation

The Correct Answer is C

A) Allowing the client time alone to sort out feelings may seem supportive, but isolation can be detrimental, especially for someone who has recently attempted suicide. Social withdrawal can exacerbate feelings of despair and hopelessness. Instead, encouraging engagement with others and structured activities is often more beneficial.

B) Avoiding discussions about subjects that upset the client can lead to avoidance coping and prevent the client from processing important emotions. While it’s important to be sensitive to triggers, avoiding difficult topics may hinder therapeutic progress. Open dialogue is essential for healing and understanding.

C) Encouraging activities that allow the client to exert control over their environment is an effective intervention. This approach helps rebuild a sense of agency and empowerment, which is crucial for clients who may feel helpless after experiencing significant losses. Engaging in structured activities can foster a sense of accomplishment and stability, which can be particularly beneficial for someone recovering from a suicide attempt.

D) Encouraging the client to interact with persons who are recovering from depression can provide valuable support and understanding; however, this may not be the most immediate intervention. The client may still be in a fragile state, and facilitating control through structured activities might be a more effective way to build confidence and a sense of community before introducing peer interactions.

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Correct Answer is D

Explanation

A) Praising the client for her new behavior can be encouraging and may boost her self-esteem. However, it’s essential to approach this cautiously, as excessive praise might overwhelm her or be perceived as insincere. While positive reinforcement is valuable, it should not be the sole focus of the intervention.

B) Offering her a choice of activities can promote autonomy and encourage engagement, but given her recent shift from despondency to exhibiting energy, it’s crucial to assess her mood and mental state carefully first. Providing choices may be helpful, but it should be accompanied by vigilant monitoring to ensure her safety.

C) Involving her in group therapy could facilitate social interaction and support, but it may not be appropriate immediately. After several days of nonverbal behavior, she may still be vulnerable. Group settings could be overwhelming, and her readiness to participate should be carefully evaluated.

D) Observing her actions continuously is the most critical action at this stage. The change in her behavior—from being despondent and nonverbal to talking and exhibiting energy—can indicate a potential shift toward increased risk for impulsivity or self-harm. Continuous observation allows the nurse to assess her safety and intervene if her behavior escalates, ensuring she is supported during this transitional phase.

A. Impaired comfort. B. Risk for injury. C. Ineffective breathing pattern. D. Ineffective coping.

Correct Answer is C

Explanation

A) Impaired comfort is a relevant concern, but it is not the highest priority in the context of a potentially life-threatening situation such as aspiration of a caustic material. While comfort is important, it is secondary to immediate safety and physiological needs.

B) Risk for injury is a general concern in many situations, but in this specific case, it does not address the acute medical implications of the aspiration of caustic material. While injury could occur, the focus should be on the immediate effects of the incident.

C) Ineffective breathing pattern is the highest priority nursing problem. Aspiration of caustic material can lead to severe respiratory complications, including airway obstruction, chemical pneumonitis, and other respiratory distress. Ensuring the client has adequate ventilation and monitoring for signs of respiratory distress are critical nursing interventions that take precedence over other concerns.

D) Ineffective coping is important to address, particularly given the context of a suicide attempt; however, it is not as immediate as the potential life-threatening consequences of aspiration and ineffective breathing. The client’s physical safety must be prioritized before addressing psychological issues.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy. Which action should the nurse implement?

Correct Answer is D

Explanation

A client is admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt. Which nursing problem has the highest priority?

Correct Answer is C

Explanation

The healthcare provider prescribes lithium carbonate for a client diagnosed with bipolar, manic depression. It is most important for the nurse to review which laboratory finding prior to beginning the drug therapy?

The mental health team working with a homeless client with chronic schizophrenia establishes the treatment goal of, "Improvement in avolition prior to discharge." Which behavior demonstrates achievement of this goal to the nurse?

A young adult client is admitted to a psychiatric facility with a diagnosis of bulimia nervosa. Which nursing intervention has the highest priority?

The nurse is leading a group on the inpatient psychiatric unit. Which approach should the nurse use during the working phase of group development?

A client with schizophrenia receives a prescription for fluphenazine. Which instruction is most important for the nurse to include when teaching the client about this drug?

A young adult client is brought to the emergency department with a suspected drug overdose. Which information is most important for the nurse to obtain from the family?

The nurse is caring for client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?