The nurse continues to care for the client.
Complete the following sentence by using the lists of options.
The client is at greatest risk for
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Rationale for Correct Choices:
- Self-harm: The client expresses suicidal ideation influenced by delusions, indicating a strong risk of acting on these impulses. In schizophrenia, command hallucinations are particularly dangerous when they involve instructions to harm oneself.
- Command hallucinations: The client reports hearing voices directing them to act, which is a hallmark of command hallucinations. These are associated with a heightened risk of harm to self or others, especially when the client appears fearful or paranoid, as in this case.
Rationale for Incorrect Choices:
- Palming medications: Although the client is suspicious and refuses medication (“I’m not letting you poison me”), there is no evidence yet of palming or hiding pills. The agitation could indicate refusal, but not covert medication avoidance.
- Poor hygiene: While the client shows confusion regarding bathing and clothing, these are not the most immediate safety threats compared to suicide risk. Poor hygiene is a concern in schizophrenia but not the most critical issue at this time.
- Impaired memory: Impaired memory is evident (e.g., forgetting routines), but this is not directly linked to a life-threatening risk. Memory issues can affect functioning but don’t explain the urgency of the client’s safety threat.
- Distractibility: The client appears distracted at times (e.g., during dressing), but distractibility alone does not account for the risk of self-harm. It contributes to disorganization but is not the main safety concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "You are feeling anxious now; why don't you give it some time before making a final decision?": This minimizes the client’s current emotional distress and does not address the seriousness of the statement. It may come across as dismissive rather than therapeutic.
B. "You should talk with your family members before making this decision.": Although involving family in major decisions can be helpful, the focus should be on the client's feelings and wishes first.
C. "I will discuss this with your primary health care provider, and we can discuss this more tomorrow.": Deferring the conversation may delay support for someone expressing emotional exhaustion and possible suicidal ideation. Prompt intervention is essential in these situations.
D. "Let me refer you to talk to someone regarding your treatment options.": This response acknowledges the client's emotional state while also offering a supportive and appropriate next step. It opens access to counseling or mental health services and helps the client explore options without judgment.
Correct Answer is C
Explanation
Rationale:
A. "I should take this medication on an empty stomach.": Amitriptyline does not require administration on an empty stomach. It can be taken with or without food, although taking it with food may help reduce gastrointestinal discomfort in some individuals.
B. "I can continue to take St. John's wort while taking this medication.": St. John's wort can increase the risk of serotonin syndrome and reduce the effectiveness of amitriptyline due to drug interactions. Clients should avoid combining herbal supplements with antidepressants.
C. "I know it will be a couple of weeks before the medication helps me feel better.": Tricyclic antidepressants like amitriptyline take 2 to 4 weeks to show noticeable improvement in mood. Recognizing the delayed onset helps set realistic expectations and supports adherence.
D. "I expect this medication to raise my blood pressure.": Amitriptyline more commonly causes orthostatic hypotension, especially when therapy is initiated. Clients should be taught to change positions slowly to reduce the risk of dizziness and falls.
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