A nurse is caring for a client who is experiencing a situational crisis.
Which of the following actions should the nurse take first?.

Reinforce teaching on the client's use of coping skills

Encourage the client to use personal support systems.

Assist with a client referral for social services.

Identify if the client has thoughts of self-harm.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Reinforcing teaching on the client’s use of coping skills is important, but it’s not the first action the nurse should take. The nurse must first ensure the client’s safety.

Choice B rationale:

Encouraging the client to use personal support systems is beneficial, but it’s not the first action. Safety is the priority.

Choice C rationale:

Assisting with a client referral for social services can be helpful, but it’s not the first action. The nurse must first assess for immediate safety risks.

Choice D rationale:

Identifying if the client has thoughts of self-harm is the first action the nurse should take. In a crisis situation, the client’s safety is the priority.

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Correct Answer is D

Explanation

Choice A rationale:

Absence of seizures is not an expected outcome of fluoxetine therapy. Fluoxetine is an antidepressant, not an anticonvulsant.

Choice B rationale:

Reduction in hand tremors is not an expected outcome of fluoxetine therapy. Fluoxetine is used to treat depression, obsessive-compulsive disorder, some eating disorders, and panic attacks.

Choice C rationale:

Decreased hallucinations is not an expected outcome of fluoxetine therapy. Fluoxetine is not typically used to treat conditions that cause hallucinations.

Choice D rationale:

Improved mood is an expected outcome of fluoxetine therapy. As an antidepressant, fluoxetine works by balancing chemicals in the brain that affect mood and emotions.

A. Alcohol use disorder B. Currently married. C. Access to guns in the home. D. Sibling history of suicide. E. Terminal liver cancer.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A rationale:

Alcohol use disorder is a risk factor for suicide. Alcohol can increase impulsivity and decrease inhibitions, which can lead to suicidal behaviors.

Choice B rationale:

Being currently married is generally considered a protective factor against suicide, not a risk factor.

Choice C rationale:

Access to lethal means, such as guns in the home, is a significant risk factor for suicide.

Choice D rationale:

A family history of suicide, including a sibling history of suicide, is a risk factor for suicide.

Choice E rationale:

Terminal illnesses, such as liver cancer, can increase feelings of hopelessness and despair, which are risk factors for suicide.

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A nurse is caring for a client who is experiencing a situational crisis. Which of the following actions should the nurse take first?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who is to start therapy with fluoxetine. Which of the following is an expected outcome for this client?.

Correct Answer is D

Explanation

A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide. Which of the following findings should the nurse identify as a risk factor for suicide? (Select all that apply.) .

Correct Answer is ["A","C","D","E"]

Explanation

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A nurse is caring for a client who is experiencing a situational crisis.
Which of the following actions should the nurse take first?.