An adolescent 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 the adolescent's mother calls the clinic nurse to report that her child became angry last night and put a fist through a window. Which intervention is most important for the nurse to implement?

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

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

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

Refer the mother for psychiatric evaluation for anxiety and depression.

Answer and Explanation

The Correct Answer is C

A. While reinforcing the need for group therapy sessions is important, it does not address the immediate safety concerns associated with violent behavior. Therapy is a long-term solution, but immediate action is necessary to prevent harm.
B. Telling the mother to describe her feelings of helplessness to the adolescent is not appropriate. It may increase the adolescent's frustration or aggression, rather than de-escalating the situation.
C. Advising the mother to call the police if violent behavior occurs again is the most important intervention. Violent actions, such as putting a fist through a window, indicate a risk for harm to self or others, and law enforcement intervention may be needed to ensure safety.
D. Referring the mother for psychiatric evaluation may be helpful if she is experiencing anxiety or depression, but it does not address the immediate concern of the adolescent's violent behavior.

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Correct Answer is B

Explanation

Rationale for A: Ineffective sexual patterns would not be the priority as the client's focus on sexual concerns appears to be delusional rather than a reflection of actual sexual dysfunction.

Rationale for B: The client is experiencing delusions, such as an inflated IQ and beliefs about being married to a movie star. These indicate altered perception of reality, making disturbed sensory perception the priority problem to address.

Rationale for C: Compromised family coping could be a concern but is not the primary issue in this situation. The client’s delusions take precedence as they directly impact his mental health and perception of reality.

Rationale for D: Impaired environmental interpretation refers to difficulty understanding the environment, but this client’s issue is more related to delusional thinking rather than misinterpretation of physical surroundings. Therefore, disturbed sensory perception is the more accurate nursing problem.

A. Efforts to cut down, annoyance with questions, guilt, drinking as an "Eye-opener." B. Consumption, liver enzyme, gastrointestinal complaints and bleeding. C. Cancer screening results, anger, gastritis, daily alcohol intake. D. Minimizes drinking, frequently misses family events, guilt about drinking, amount of daily intake.

Correct Answer is A

Explanation

A. The CAGE questionnaire focuses on four key aspects related to alcohol use: efforts to Cut down, Annoyance with questions about drinking, feelings of Guilt about drinking, and using alcohol as an "Eye-opener" in the morning. Exploring these aspects in depth can provide valuable information about the client's relationship with alcohol and potential problems.

B. While information about consumption, liver enzymes, and gastrointestinal complaints is important for assessing alcohol-related issues, these are not specifically addressed by the CAGE questionnaire.
C. Cancer screening results, anger, gastritis, and daily alcohol intake are relevant to assessing the client's overall health and alcohol use but are not directly related to the questions asked in the
CAGE questionnaire.
D. While information about minimizing drinking, missing family events, guilt about drinking, and daily alcohol intake may provide insight into the client's alcohol use, these aspects are not specifically addressed by the questions in the CAGE questionnaire.

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Naxlex Comprehensive Predictor Exams

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

Correct Answer is B

Explanation

The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in depth with the client based on this screening tool?

Correct Answer is A

Explanation

The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

A client engages in repeated checks of door and window locks and behavior that prevents the client from arriving on time and interfering with the ability to function effectively. Which action should the nurse take?

When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?

An adult female client is brought to the Emergency Center after fainting at work. The nurse completes an assessment of the client and identifies caregiver role strain as a nursing problem. Which information best supports this problem?

The nurse has received a new prescription for the client to begin taking sertraline. Prior to administering the initial dose of sertraline, it is most important for the nurse to obtain which information?