Following the visit, what are appropriate actions for the nurse? Select all that apply.

Mail education items to the home for batterer treatment options

Provide referrals from the physician for mental health services

Follow up with the client in a few weeks

Call the police as a mandatory reporter

Document verbatim statements about the abuse

Answer and Explanation

Correct Answer : B,C,E

A.   Mailing education items to the home for batterer treatment options might not be appropriate without the client's consent or discussion.
B.   Providing referrals for mental health services aligns with addressing the client's needs.
C.   Following up with the client in a few weeks ensures continuity of care and monitoring of the client's progress.
D.   Calling the police as a mandatory reporter might be necessary if there's an immediate threat, but it's not mentioned in the scenario.
E.   Documenting verbatim statements about the abuse is crucial for accurate record-keeping and legal purposes.

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Correct Answer is C

Explanation

A. Isolating the client might exacerbate feelings of social exclusion and isn't the best approach for managing echolalia.
B. Administering a sedative should not be the initial response to echolalia unless the behavior poses immediate harm to the client or others.
C. Escorting the client to a private area can help reduce the annoyance to other clients without isolating or punishing the individual.
D. Avoiding recognition of the behavior doesn't address the issue and might negatively impact the therapeutic relationship.

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

Correct Answer is D

Explanation

A. While liver enzymes and gastrointestinal complaints are important, they are not part of the CAGE questionnaire.
B. Cancer screening results, anger, and gastritis are not directly addressed by the CAGE questionnaire.
C. The listed items are relevant but not specifically addressed by the CAGE questionnaire.
D. Efforts to cut down, annoyance with questions, guilt, and drinking as an "eye-opener" are aspects explored in the CAGE questionnaire to assess alcohol dependency.

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Following the visit, what are appropriate actions for the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. Which intervention is best for the nurse to implement?

Correct Answer is C

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 D

Explanation

The nurse plans to use role-playing as a therapeutic measure. Which individual is most likely to benefit from this type of therapeutic intervention?

The nurse is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview?

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?

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

The nurse is conducting client assessments in an outpatient psychiatric clinic. Which client finding is characteristic of illness anxiety disorder?

A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?

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