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. "The snakes on the wall are going to eat me" indicates a hallucination, specifically a visual hallucination. Hallucinations involve perceiving something that is not present, such as seeing or hearing things that others do not. This statement does not confirm delusions.

B. Hearing voices instructing harm doesn't confirm delusions but auditory hallucinations.

C. "The nurse at night is trying to poison me with pills" reflects a delusion, specifically a persecutory delusion. Delusions are false, fixed beliefs that are not based in reality and are resistant to reasoning or contradictory evidence. This statement indicates a belief that someone is attempting harm, which is characteristic of delusional thinking.

D. Believing fire is burning the skin could suggest a hallucination involving sensations, not necessarily a delusion.

A. Returns to her previous level of functioning. B. Identifies four of her positive personal traits. C. Initiates an exercise program to help deal with stress. D. Describes what she wants from a romantic relationship.

Correct Answer is A

Explanation

A. Returning to a previous level of functioning is essential for someone hospitalized due to an overdose as it ensures their safety and stability.
B. Identifying personal traits might be a part of therapy but is not the primary goal immediately after an overdose.
C. While exercise can be beneficial, it's not the primary concern right after a suicide attempt.

D. Discussing relationship needs is important but not the immediate priority after a suicide attempt.

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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

The nurse documents that a male client with schizophrenia is delusional. Which statement by the client confirms this assessment?

Correct Answer is C

Explanation

A female college student is admitted to the mental health unit following a drug overdose. The student tells the nurse that she took the overdose following the end of a romantic relationship. Which is the primary goal for hospitalization that should be included in this client's plan of care?

Correct Answer is A

Explanation

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease-related?

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 assessing a client whose spouse died of a stroke two weeks ago and who reports having numbness and tingling on the right side of the body. The nurse should consider the client's symptoms may likely be due to which condition?

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

The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?

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?

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?

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