The nurse should frequently assess a client with a depressive disorder for lethality risk related to suicidal ideation. Which questions should the nurse include? (Select all that apply.)

"Where do you keep your gun?"

"Are you thinking about hurting yourself or someone else?"

"Have you thought about how you would hurt yourself?"

"Can you tell me your feelings about dying?"

"Have you told your psychiatrist you feel like dying?"

Answer and Explanation

Correct Answer : A,B,C,D

Choice A reason: While it’s important to assess access to lethal means, this question is too specific and assumes the client owns a gun. A more appropriate question might be, “Do you have access to any means to harm yourself?”

Choice B reason: Inquiring about thoughts of self-harm or harming others is a direct question that assesses suicidal ideation and intent, which is essential for determining immediate risk.

Choice C reason: Understanding if the client has specific plans for self-harm can help gauge the immediacy and seriousness of the suicide risk.

Choice D reason: Discussing feelings about dying can provide insight into the client's emotional state and potential risk for suicide.

Choice E reason: This question is important but it should not replace direct questions about the client’s current thoughts and feelings. It’s possible for a client to deny feelings of suicidality to their psychiatrist while still experiencing them.

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Correct Answer is A

Explanation

Choice A reason: For a client with Alzheimer's disease, it is beneficial to talk them through tasks one step at a time to help maintain their cognitive function and independence for as long as possible. This approach can reduce confusion and frustration.

Choice B reason: While rotating caregivers might provide variety, it can be confusing for a client with Alzheimer's disease. Consistency in caregivers can help establish a routine and sense of familiarity, which is comforting and can reduce anxiety.

Choice C reason: A consistent daily activity schedule is crucial for clients with Alzheimer's disease. It helps to maintain a sense of normalcy and can reduce stress and confusion. Changing the schedule daily could lead to increased anxiety and disorientation.

Choice D reason: Allowing ample time for activities is important as rushing can cause stress and agitation in clients with Alzheimer's disease. They often require more time to process information and complete tasks due to cognitive impairments.

A. Urinary retention and constipation B. Fine hand tremors and pill rolling C. Tongue thrusting and lip smacking D. Facial grimacing and eye blinking E. Involuntary pelvic rocking and hip thrusting movements

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

Explanation

Choice A reason: Urinary retention and constipation are not typically associated with tardive dyskinesia, which is characterized by involuntary movements.

Choice B reason: Fine hand tremors and pill rolling are more commonly associated with Parkinson's disease rather than tardive dyskinesia.

Choice C reason: Tongue thrusting and lip smacking are classic signs of tardive dyskinesia, often resulting from long-term use of antipsychotic medications.

Choice D reason: Facial grimacing and eye blinking are also indicative of tardive dyskinesia, reflecting involuntary facial movements.

Choice E reason: Involuntary pelvic rocking and hip thrusting movements can be manifestations of tardive dyskinesia, representing involuntary movements of the body.

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The nurse should frequently assess a client with a depressive disorder for lethality risk related to suicidal ideation. Which questions should the nurse include? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? Select all that apply.

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

Explanation

The nurse has established a therapeutic relationship with a client. Which behaviors indicate that the client has entered into the identification phase of the nurse-client relationship?

The nurse is talking with a client who grew up in a home where both parents were alcoholics. Which behaviors does the nurse identify when assessing this client that correlate with this home life? Select all that apply.

A client diagnosed with Schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should the nurse expect a physician to order to address this type of symptom?

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A male nurse is assigned to care for a female client who was admitted to the hospital for treatment of injuries following a domestic abuse incident. The client expresses discomfort with a male nurse as her caregiver. Which response should the nurse manager provide?

The nurse is planning the type of approach that will be most effective in developing a therapeutic relationship with the client. With which types of personality disorders should the nurse use a matter-of-fact approach? (Select all that apply)

The nurse is educating a client and family about strategies to minimize the side effects of antipsychotic drugs. Which will be included in the plan? Select all that apply.