The nurse continues caring for the client

Nurses' Notes

• Diagnosis: depression and post-traumatic stress disorder Diphenhydramine 12.5 mg PO every night at sleep (HS) • Buspirone hydrochloride 7.5 mg PO twice a day

During the conversation with the client, the nurse documents a statement by the client about wishing she had died in the crash.

Choose the most likely options for the information missing from the statement by selecting from the list of options provided.

The statement by the client represents and should be followed up with an

Answer and Explanation

The Correct Answer is ["suicidal ideation"," assessment of risk factors for suicide"]

In the context of mental health care, a statement by a client expressing a wish to have died in a traumatic event is indicative of suicidal ideation. This is a serious concern and warrants immediate and careful attention from the healthcare provider. The appropriate response involves conducting a thorough assessment of risk factors for suicide, which may include evaluating the client's mental health history, current stressors, support systems, and any previous suicide attempts or self-harm behavior. This assessment is crucial in determining the level of risk and the need for potential interventions, which may range from close monitoring to emergency psychiatric evaluation. It is essential for healthcare professionals to approach such situations with sensitivity, providing support and ensuring the safety of the client as a priority.

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Correct Answer is C

Explanation

A. While excessive alcohol consumption can contribute to cardiovascular issues, including heart attacks, methamphetamine abuse is associated with a higher risk of myocardial infarction due to its potent sympathomimetic effects on the cardiovascular system.
B. Benzodiazepines primarily affect the central nervous system and are not typically associated with an increased risk of myocardial infarction.
C. Methamphetamine use is known to cause significant cardiovascular effects, including increased heart rate, blood pressure, and vasoconstriction, which can lead to myocardial infarction.
D. While marijuana use can have cardiovascular effects, it is generally less potent in its cardiovascular effects compared to methamphetamine.

A. Current vital signs. B. White blood cell count. C. 24-hour urinary output. D. Blood sugar level.

Correct Answer is A

Explanation

A. Current vital signs are essential for assessing for neuroleptic malignant syndrome (NMS), a potentially life-threatening side effect of antipsychotic medications like haloperidol. Vital signs such as temperature, blood pressure, heart rate, and respiratory rate are crucial indicators of
NMS.

B. While monitoring white blood cell count may be important for detecting infections or adverse reactions to medications, it is not specific to assessing for NMS.
C. Monitoring 24-hour urinary output may be important for assessing renal function but is not specific to assessing for NMS.
D. Monitoring blood sugar levels may be important for clients with diabetes or those at risk of hyperglycemia due to medication effects, but it is not specific to assessing for NMS.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing intake interviews at a psychiatric clinic. A client with a known history of drug abuse reports having had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction?

Correct Answer is C

Explanation

A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?

Correct Answer is A

Explanation

The nurse caring for this client is working with a new nurse. The nurse teaches the novice nurse about the legal and ethical issues surrounding the client's case. Mark whether the statement by the student nurse indicates understanding or no understanding.

The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

During a family group meeting, the client's daughter tells the group, "I hope I didn't cause Mom to be depressed." Which response is best for the nurse to provide?

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?

The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?

The nurse wants to teach the client about the long-term phase symptoms of rape-trauma syndrome. What symptoms are consistent with long-term rape trauma? Select all that apply.