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) Request backup from the staff:Requesting backup may be necessary if the situation escalates and the client poses a threat to themselves or others. However, it should not be the first action. The nurse should initially attempt to de-escalate the situation by addressing the client’s immediate needs and providing personal space.

B) Encourage the client to sit down:Encouraging the client to sit down might help reduce their agitation, but it could also be perceived as controlling or dismissive. The nurse should first focus on creating a safe environment by providing personal space and then assess the client’s willingness to sit down.

C) Stand in the doorway:Standing in the doorway can provide the nurse with a quick exit if needed, but it may also make the client feel trapped or cornered. It is important to maintain a non-threatening posture and ensure the client has enough space to feel comfortable.

D) Provide for personal space:Providing personal space is crucial in managing aggressive behaviors. It helps to reduce the client’s sense of threat and allows them to feel more in control. This approach can help de-escalate the situation and create a safer environment for both the client and the nurse.

A. Schedule the client for group therapy with other bulimic clients. B. Assign the client's care to a nurse of approximately the same age. C. Assess and report the client's electrolyte status to the healthcare provider. D. Monitor the client carefully for binging activities.

Correct Answer is C

Explanation

A) Scheduling the client for group therapy with other bulimic clients can be beneficial for support and shared experiences. However, it is not the highest priority intervention at the time of admission, especially if there are immediate health concerns that need to be addressed.

B) Assigning the client's care to a nurse of approximately the same age may help with rapport and understanding, but it does not directly address the critical health risks associated with bulimia nervosa. The age of the nurse is less relevant compared to the immediate medical needs of the client.

C) Assessing and reporting the client's electrolyte status to the healthcare provider is the highest priority. Clients with bulimia nervosa often experience significant electrolyte imbalances due to behaviors such as vomiting, laxative use, or excessive exercise, which can lead to serious complications such as cardiac arrhythmias. Monitoring electrolyte levels is essential for ensuring the client’s safety and guiding further treatment.

D) Monitoring the client carefully for binging activities is an important part of care, but it is secondary to addressing any immediate medical concerns. While observation is necessary to prevent harm, it should occur alongside medical assessments, particularly for electrolyte status, to ensure comprehensive care.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When responding to a call light, the nurse finds a client with aggressive behaviors pacing and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?

Correct Answer is D

Explanation

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

Correct Answer is C

Explanation

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

The nurse is assessing a client with postpartum depression for changes in the mood and cognitive state. Which subjective finding(s) should the nurse identify that are consistent with postpartum depression? Select all that apply.

A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit's day room. Which action should the nurse implement first?

A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and amotivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

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 female client admitted to the mental health unit starts to shout and scream at the nurse. Which is the best approach for the nurse to take?

A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. While approaching the client, which intervention should the nurse implement first?