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,A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling
and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How
should the nurse interpret this behavior as a cue to modify the treatment plan?
1.
Suggesting a reduction of medication
2.
Allowing increased "in-room" activities
3.
Increasing the level of suicide precautions
4.
Allowing the client off-unit privileges as needed
3
(pt who is moderately depressed and has only been in the hospital 2 days is unlikely to
have such a dramatic cure. When a depression suddenly lifts, it is likely that the client may
have made the decision to harm himself or herself. Suicide precautions are necessary to
keep the client safe)
,The emergency department nurse is caring for an adult client who is a victim of family
violence. Which priority instruction should be included in the discharge instructions?
1.
Information regarding shelters
2.
Instructions regarding calling the police
3.
Instructions regarding self-defense classes
4.
Explaining the importance of leaving the violent situation
1
A female victim of a sexual assault is being seen in the crisis center. The client states
that she still feels "as though the rape just happened yesterday," even though it has been
a few months since the incident. Which is the most appropriate nursing response?
1.
"You need to try to be realistic. The rape did not just occur."
2.
"It will take some time to get over these feelings about your rape."
3.
"Tell me more about the incident that causes you to feel like the rape just occurred."
4.
"What do you think that you can do to alleviate some of your fears about being raped
again?"
3
(trash response irl though)
, A client is admitted to the mental health unit after an attempted suicide by hanging. The
nurse can best ensure client safety by which action?
1.
Requesting that a peer remain with the client at all times
2.
Removing the client's clothing and placing the client in a hospital gown
3.
Assigning to the client a staff member who will remain with the client at all times
4.
Admitting the client to a seclusion room where all potentially dangerous articles are
removed
3