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?

Usual level of activity and average sleep pattern.

Blood pressure when sitting and standing.

Dentures to determine if they are poorly fitted.

Body weight over the past three months.

Answer and Explanation

The Correct Answer is C

A.   Assessing the usual level of activity and average sleep pattern is relevant but does not directly address the observed symptoms related to speech and tongue movements.
B.   Blood pressure assessment is important for overall health monitoring but is not the most immediate concern related to the observed speech and tongue abnormalities.
C. Assessing the fit of dentures is crucial in this context, as poorly fitted dentures could contribute to speech difficulties and tongue abnormalities.
D.   Body weight assessment is important for overall health but is not the most immediate concern in this situation. Assessing denture fit addresses the observed speech and tongue abnormalities more directly.

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Correct Answer is ["A","B","D"]

Explanation

Rationale for A: Reinforcing a will to live and encouraging realistic future plans can promote hope and motivation in a depressed adolescent.

Rationale for B: Discussing the client’s suicide plan is essential for assessing risk and ensuring safety. It allows for intervention if the risk is significant.

Rationale for C: While managing screen time can be beneficial, it is less critical than addressing the underlying emotional issues and ensuring safety.

Rationale for D: Encouraging the client to express thoughts and feelings about wanting to die can provide a safe space for the adolescent to discuss suicidal ideation and help the nurse assess risk more effectively.

Rationale for E: Restricting visitors may not be helpful; maintaining social connections can provide support and reduce feelings of isolation.

A. A nurse who works in a pediatric emergency department. B. An adolescent male whose parents recently divorced. C. A retired older male whose significant other has passed away. D. A single working mother with three preschool-aged children.

Correct Answer is B

Explanation

A. While working in a pediatric emergency department can be stressful, the information provided does not suggest an increased risk for suicide in this scenario.
B. Adolescents experiencing major life changes, such as parental divorce, are at an elevated risk for suicide.
C. While the loss of a significant other can contribute to increased suicide risk in older adults, the information provided does not indicate an immediate concern.
D. While being a single working mother with young children is challenging, the information provided does not suggest an increased risk for suicide in this scenario.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is ["A","B","D"]

Explanation

Which individual should the nurse consider at the highest risk for suicide?

Correct Answer is B

Explanation

While visiting the community mental health center, a client with a diagnosis of major depressive disorder asks the nurse if what is shared with the staff will be shared with family members. How should the nurse respond to this client?

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?

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?

The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued?

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?

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