When a male client is asked about his reason for coming to the mental health clinic, he replies, “It all started because I work in a hostile work environment. My boss would not let me go to a religious service, so I went to human resources, and they didn’t want to do anything. It has been a really difficult time for me.” Which response should the nurse provide?

Why do you think you have a hostile work environment?

Have you considered resigning from your position?

Have the feelings associated with these events brought you to the clinic?

How have you responded to those in your work environment about these events?

Answer and Explanation

The Correct Answer is C

A.   This question may be perceived as confrontational. It is essential to explore the client's feelings and experiences first.
B.   Asking about resignation is premature at this stage. Exploring feelings and experiences is more appropriate initially.
C. This response acknowledges the client's feelings and experiences, allowing for further exploration of the issues that brought him to the clinic.
D.   This question is more focused on the client's actions rather than exploring the emotional impact of the events. The nurse should first understand the client's feelings before addressing actions or solutions.

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Correct Answer is B

Explanation

A. Assessing intake and output is important for overall monitoring but does not address the specific concerns related to heroin detoxification.
B. Monitoring for wheezing and apnea is crucial during the first 24 hours after admission for heroin detoxification to ensure respiratory stability.
C. Limiting visitors is a general precaution but may not be the most important intervention related to the physiological effects of heroin detoxification.
D. Assigning the client to a teen support group is a valuable intervention for overall support but may not address the immediate physiological concerns of heroin detoxification.

A. Tell the client to call Adult Protective Services if his son’s abuse continues. B. Verify the client’s report by determining if there is physical evidence of abuse. C. Refer the client to a program for victims of domestic violence. D. Assist the client in developing an emergency safety plan.

Correct Answer is D

Explanation

A. Telling the client to call Adult Protective Services is a valid intervention, but immediate safety planning is crucial.
B. Verifying the client's report by determining physical evidence is important but may not be the most immediate and practical intervention.
C. Referring the client to a program for victims of domestic violence is a valuable option, but immediate safety planning should take precedence.
D. Assisting the client in developing an emergency safety plan is the most important intervention to ensure the client's safety in the present situation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adolescent who is a heroin addict is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?

Correct Answer is B

Explanation

An older man with a history of multiple falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become increasingly abusive since his release from prison six weeks ago. Which intervention is most important for the nurse to implement?

Correct Answer is D

Explanation

While assessing a client with the diagnosis of schizophrenia who wears dentures, the nurse observes that the client’s tongue is “worming”. The client also demonstrates an inability to articulate words clearly. Which additional assessment is most important for the nurse to obtain?

A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. Which action should the nurse implement first?

After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping both feet while pacing the hallway. Which action should the nurse take?

A homeless female client who reports feeling sad and depressed tells the mental health nurse that in the past two days, the client has only had four hours of sleep. Which action is most important for the nurse to implement within the first 24 hours after treatment is initiated?

The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?

An adolescent female with an eating disorder is admitted to the in-patient psychiatric unit. Which intervention should the nurse implement?

The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the client’s history should the nurse further explore?