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?

Provide the client with a written hospital policy regarding privacy of information laws.

Tell the client that confidentiality will be maintained, except when one’s safety is threatened.

Nod in the affirmative, but make no verbal commitment to the client.

Assure the client that information provided will be shared with the staff only.

Answer and Explanation

The Correct Answer is B

A.   Providing the client with written information about privacy laws is a good practice, but a verbal explanation is also necessary to address the immediate concern.
B.   This response provides accurate information about confidentiality while acknowledging exceptions when safety is at risk.
C. Non-verbal gestures may be ambiguous and could lead to misunderstandings. It's important to communicate clearly with the client.
D.   Assuring the client that information will be shared only with the staff may not be entirely accurate, as there are situations where confidentiality must be breached, such as when safety is a concern.

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Correct Answer is C

Explanation

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.

A. Decreased prothrombin time and partial thromboplastin levels B. Increased values of serum levels for liver function profile C. Increasingly larger amounts of alcohol are needed to feel drunk D. Periodic indigestion with negative occult blood in stool. E. Memory lapses of events that occurred when drinking.

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

Explanation

A. Chronic alcohol use is more likely to be associated with increased prothrombin time and partial thromboplastin levels due to impaired liver function.
B. Increased values of serum levels for liver function profile (such as AST, ALT, GGT) are common in individuals with chronic alcohol dependency.
C. Tolerance, where increasingly larger amounts of alcohol are needed to feel drunk, is a characteristic feature of alcohol dependency.
D. Periodic indigestion and negative occult blood in the stool may be indicative of alcohol- related gastrointestinal issues.
E. Memory lapses, especially blackouts or amnesia regarding events that occurred during drinking, are common in chronic alcohol use and dependency.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

A client with chronic alcohol dependency is admitted due to a recent relapse. Which findings should the nurse expect this client to exhibit? (Select all that apply)

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

Explanation

An adolescent who is exhibiting a depressed affect receives a prescription for an antidepressant drug. While the client is taking the antidepressant, which comparison of the client’s behavior before and after taking the drug is most important for the nurse to obtain?

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

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?

A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client’s rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?

A client is admitted to an inpatient psychiatric unit, and the antipsychotic medication clozapine is prescribed. Which intervention should the nurse include in this client’s plan of care?

Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?

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?