An adolescent male who was arrested a month ago for gang-related activities has a court order to attend weekly group therapy sessions at the mental health clinic. Today his mother calls the clinic nurse to report that her son became angry last night and put his fist through a window. Which intervention is most important for the nurse to implement?

Advise the mother to call the police if violent behavior occurs again.

Refer the mother for psychiatric evaluation for anxiety and depression.

Reinforce the need for the adolescent to attend group therapy sessions.

Tell the mother to describe her feelings of helplessness to her son.

Answer and Explanation

The Correct Answer is A

A.   Advising the mother to call the police if violent behavior occurs again addresses the safety of the client and others and is a necessary step to ensure appropriate intervention.
B.   Referring the mother for psychiatric evaluation is important but may not directly address the immediate safety concern related to the recent violent behavior.
C. Reinforcing the need for the adolescent to attend group therapy sessions is relevant, but the immediate focus should be on addressing the safety issue.
D.   Telling the mother to describe her feelings may be helpful for therapeutic communication but may not be the most urgent intervention in response to the reported violent behavior.

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Correct Answer is C

Explanation

A. Level of activity, interactions with others, and appetite are important aspects, but the emotional quality of attitude is central in assessing the effectiveness of an antidepressant.
Changes in mood and affect are critical indicators of the drug's impact on the client's mental health.
B. Interactions with others provide valuable information but may not capture the internal emotional experience of the client.
C. The emotional quality of attitude reflects the client's internal state and is a key indicator of the antidepressant's impact on their depressive symptoms.
D. Appetite is a relevant aspect, but it may not be as direct an indicator of the antidepressant's efficacy as changes in the emotional quality of attitude.

A. A nurse who works in a pediatric emergency department. B. An adolescent male whose parents recently divorced. C. A retired older male whose significant other has passed away. D. A single working mother with three preschool-aged children.

Correct Answer is B

Explanation

A. While working in a pediatric emergency department can be stressful, the information provided does not suggest an increased risk for suicide in this scenario.
B. Adolescents experiencing major life changes, such as parental divorce, are at an elevated risk for suicide.
C. While the loss of a significant other can contribute to increased suicide risk in older adults, the information provided does not indicate an immediate concern.
D. While being a single working mother with young children is challenging, the information provided does not suggest an increased risk for suicide in this scenario.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

Which individual should the nurse consider at the highest risk for suicide?

Correct Answer is B

Explanation

A client with post-traumatic stress disorder (PTSD) is experiencing a dissociative disorder episode. The situation quickly escalates, and the client becomes physically aggressive. Which intervention should the nurse implement first?

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?

A client who is experiencing a severe level of anxiety reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?

The nurse completes an assessment of a client experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?

During a high school substance abuse class, a student tells the group, “I know that marijuana is not addicting, so why shouldn’t I use it? Which response is best for the nurse to provide?

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. In approaching the client, what intervention should the nurse implement first?

The nurse is caring for a client who is a refugee from another country and who is experiencing daily episodes of anxiety. The client communicates minimally with the nurse, looking away and appearing distressed. Which intervention is most important for the nurse to do first?