Which interventions should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)

A client with opioid dependence makes a statement to the nurse about desiring to lead a healthier lifestyle by making changes in the next 2 weeks. How should the nurse respond?

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?

During a one-to-one session with the nurse, a female client admitted for chronic depression and attempted suicide discloses experiences of sexual promiscuity and prostitution. When the nurse asks the client if she was ever sexually abused as a child, the client says, “I don’t remember, but my mother ran my father off when I was five.” The nurse should recognize that the client may be using which defense mechanism?

The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?

An adult client presents to the community mental health center accompanied by the client’s spouse who reports that the client has been acting impulsively. The client has spent a large amount of money lately, made several last-minute decisions to take trips, sleeps only 2 to 4 hours a night, and has lost 33 pounds (15 kg) in the last 2 months. Which nursing problem has the greatest nursing priority?

An adolescent male who was arrested a month ago for gang-related activities has a court order to attend weekly group therapy sessions at the mental health clinic. Today his mother calls the clinic nurse to report that her son became angry last night and put his fist through a window. Which intervention is most important for the nurse to implement?

The nurse is caring for a client who has been the victim of intimate partner violence. During the interview, the nurse feels angry, embarrassed, and helpless. Which explanation best describes the cause of the nurse’s emotions?

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?

A young adult male client is admitted to the psychiatric unit because of a recent suicide attempt. His wife filed for divorce six months ago, he lost his job three months ago, and his best friend moved to another city two weeks ago. Which intervention should the nurse include in this client’s plan of care?

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?