86 mm Hg

Oxygen saturation 99%

A nurse is caring for a client who is grieving. Which of the following findings should the nurse identify as a priority to address? Select all that apply.

Statement regarding outlook on living

Statement related to feelings of sadness and anger.

Knowledge of expectations during group meetings.

Awareness of the therapist's role.

Statement related to use of pharmacological interventions.

Question Solution

Correct Answer : A,B,E

Rationales:

A. The client's statement, "I can't go on living without my child," indicates a potentially serious risk to their safety and well-being. This statement suggests that the client may be experiencing suicidal ideation or extreme despair, which requires immediate attention and intervention.

B. While sadness and anger are expected components of grief, the intensity of these feelings and their persistence need to be assessed for any signs of complicated grief or potential for self-harm. Addressing these emotions is critical to ensuring the client’s safety and providing appropriate support.

C. While understanding the expectations during group meetings is important for therapy, it is not as immediately critical as addressing the client's statements about their outlook on living and their medication adherence.

D. Knowledge about the therapist’s role is important for therapeutic alliance, but it is less urgent compared to addressing the client’s potentially dangerous outlook on living and their medication issues.

E. The client’s refusal to take the prescribed medication, with the belief that it "will not help," indicates a possible issue with medication adherence or effectiveness. This needs to be addressed to ensure that the client is receiving appropriate treatment for their mental health needs.

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A. "A suicide attempt is the manner in which someone kills themselves. Self-harm is just the person acting out." B. "A suicide attempt is when a person harms themselves with the intent to die but does not. Self-harm is when a client intentionally inflicts harm on themselves but does not have intention to kill themselves." C. "When a client attempts suicide, they do so in a manner by causing self-harm." D. "The two terms are the same and can be used interchangeably." E. Body dysmorphism

Correct Answer is B

Explanation

Rationale:

A. This response incorrectly defines suicide attempts and self-harm and oversimplifies the concept of self-harm.

B. A suicide attempt involves self-harm with the intent to die, whereas self-harm (or self-injury) involves harming oneself without the intention of death. This response accurately differentiates between the two.

C. Suicide attempts can involve self-harm, but not all self-harm is intended as a suicide attempt. This response conflates the terms.

D. The terms are not interchangeable; understanding their differences is crucial for accurate assessment and intervention.

A. Biologically male clients are typically diagnosed earlier than biologically female clients. B. Biologically female clients are likely to be diagnosed earlier than biologically born males. C. Diagnosis commonly occurs in individuals under the age of 12. D. People diagnosed with schizophrenia are more violent than others.

Correct Answer is A

Explanation

Rationale:

A. Schizophrenia is typically diagnosed earlier in males compared to females, with onset often occurring in late adolescence to early adulthood.

B. Biologically female clients are generally diagnosed later in life compared to males.

C. Schizophrenia is rarely diagnosed in individuals under the age of 12; it commonly presents in late adolescence or early adulthood.

D. People with schizophrenia are not necessarily more violent than others; rather, violence is not a defining characteristic of the disorder.

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Correct Answer is B

Explanation

Correct Answer is A

Explanation

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A newly licensed nurse asks a charge nurse, "What is the difference between a suicide attempt and self-harm?" Which of the following responses should the charge nurse give?

Correct Answer is B

Explanation

A nurse is caring for a client who has been newly diagnosed with schizophrenia. Which of the following findings is true regarding this disorder?

Correct Answer is A

Explanation

A nurse is preparing to administer a unit of red blood cells. The nurse's responsibility is to compare and verify the information on the blood label with the client's information. The nurse should use which of the following as the priority source of verification?

A nurse is caring for a client who has a serious mental illness and has developed tardive dyskinesia from anti-psychotic medication use. Which of the following adverse effects from anti-psychotic medication use would be expected for the client?

A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?

A nurse is caring for a client who has depression. Which of the following noninvasive treatments should the nurse recommend to the client?

A newly hired nurse is providing report to a nurse. The nurse continuously interrupts the newly hired nurse during report. This is an example of which of the following?

A nurse is caring for a client who has illness anxiety disorder. Which of the following medications should the nurse expect the provider to prescribe?

A nurse is discussing borderline personality disorder and the risk for self-harm with a newly licensed nurse. Which of the following situations should the nurse identify as the highest risk for self-harm?

A nurse is preparing for a home visit with a client whose partner recently died by suicide. Which of the following actions should the nurse take first when preparing to provide client-centered care?

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