A young adult male client is admitted to the psychiatric unit because of a recent suicide attempt. His wife filed for divorce six months ago, he lost his job three months ago, and his best friend moved to another city two weeks ago. Which intervention should the nurse include in this client’s plan of care?

Avoid discussing subjects that upset the client

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

Allow the client time alone to sort out his feelings.

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

Answer and Explanation

The Correct Answer is B

A.   Avoiding discussing subjects that upset the client may hinder therapeutic communication and exploration of feelings, making it less effective for the client's recovery.
B.   Encouraging activities that allow the client to exert control over his environment helps empower the client and regain a sense of agency, which is important for improving mental health.
C. Allowing the client time alone may be appropriate at times, but encouraging activities that promote control is a more proactive and empowering intervention.
D.   Encouraging interaction with persons recovering from depression may be beneficial, but the client's need for control over his environment takes precedence in this scenario.

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Correct Answer is D

Explanation

A. Determine the client’s reason for attempting suicide: While assessing suicidal intent is important, the immediate priority is ensuring the client's physiological stability. Suicidal ideation can be addressed once the client is medically stable.

B. Obtain the client’s serum hydrocodone/acetaminophen level: This may be ordered, but it is not the highest priority. Clinical observation is more urgent, especially because naloxone has a shorter half-life than many opioids, including hydrocodone.

C. Encourage the client to increase fluid intake: This is not a priority intervention in the immediate post-overdose period and does not address the risk of opioid rebound toxicity.

D. Observe the client for further narcotic effects: Naloxone has a short duration of action (typically 30–90 minutes), whereas hydrocodone has a longer half-life. Once naloxone wears off, respiratory depression and sedation can recur. Continuous monitoring is critical to ensure timely re-administration if opioid effects return.

A. Inquire about the client’s support system. B. Ask the client to repeat his comment. C. Stop the client from leaving the ED. D. Record the statement in the client’s chart.

Correct Answer is C

Explanation

A. Inquiring about the client’s support system may be important, but the immediate concern is the statement indicating a potential risk of harm.
B. Asking the client to repeat the comment may not be as effective as taking immediate action to prevent harm.
C. Stopping the client from leaving the ED is the priority to ensure the client's safety and prevent the potential act of self-harm.
D. Recording the statement in the client's chart is important but should be done after taking immediate action to address the potential risk.

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Naxlex Comprehensive Predictor Exams

Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

A homeless female client who reports feeling sad and depressed tells the mental health nurse that in the past two days, the client has only had four hours of sleep. Which action is most important for the nurse to implement within the first 24 hours after treatment is initiated?

A client is admitted to an inpatient psychiatric unit, and the antipsychotic medication clozapine is prescribed. Which intervention should the nurse include in this client’s plan of care?

A client with generalized anxiety disorder (GAD) receives a new prescription for lorazepam. Which statement provided by the client requires additional instruction by the nurse?

An adolescent who is exhibiting a depressed affect receives a prescription for an antidepressant drug. While the client is taking the antidepressant, which comparison of the client’s behavior before and after taking the drug is most important for the nurse to obtain?

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 preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued?

While assessing a client with the diagnosis of schizophrenia who wears dentures, the nurse observes that the client’s tongue is “worming”. The client also demonstrates an inability to articulate words clearly. Which additional assessment is most important for the nurse to obtain?

An adolescent who is a heroin addict is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?