Uworld Mental Health Nursing Test Questions and Answers (Verified 2023)

Mental Health Nursing Test Id: Question Id: 32261 () A speeding driver sustained a closed-head injury in an acceleration/deceleration accident from striking a tree front end f irst. Based on the coup-contrecoup phenomenon, which assessments are most likely to be affected related to the involved areas of the brain? Unordered Options Ordered Response 1. Expressive speech, vision 2. Light touch, hearing 3. Sense of position, graphesthesia 4. Weber tuning fork test, cranial nerve I Explanation Coup-contrecoup injury occurs when a body in motion stops suddenly (eg, head hits car windshield), causing contusions (bruising) of brain tissue as the brain moves back and forth within the skull. First, the soft tissue strikes the hard skull in the same direction as the momentum (coup). As the body bounces back, the brain strikes the opposing side of the skull (contrecoup). When the forward collision occurred, the frontal lobe most likely suffered the primary impact (coup). Executive function, memory, speech (Broca area), and voluntary movement are controlled by the frontal lobe. The contrecoup most likely injured the occipital lobe, where vision is processed. (Option 2) The temporal lobe (lateral aspect of the brain) controls hearing and integrates sensory data (eg, auditory, visual, somatic). The Wernicke speech area in the temporal lobe is responsible for language comprehension. Light touch is processed by the sensory cortex in the parietal lobe. (Option 3) An interruption of sensory function indicates injury to either the spinal column or the parietal lobe. These injuries affect proprioception (awareness of body positioning) and graphesthesia (ability to identify writing on the skin, by touch). (Option 4) The Weber test screens for conductive hearing loss by checking whether a tuning fork held along the midline of the head is heard evenly in both ears. Cranial nerve I is the olfactory nerve. Hearing and smell are both processed by the temporal lobe. Educational objective: Coup-contrecoup injuries usually affect the frontal and occipital lobes. The frontal lobe controls executive function, memory, speech, and motor skills. The occipital lobe processes vision. Test Id: Question Id: 31967 () The student nurse is performing an assessment of a 10-year-old diagnosed with attention-deficit hyperactivity disorder (ADHD). In addition to the 3 core symptoms of ADHD (hyperactivity, impulsiveness, and inattention), which of the following would the student nurse expect to find during the assessment? Unordered Options Ordered Response 1. Confusion and a learning disability 2. Delayed physical and emotional development 3. Disorientation and cognitive impairment 4. Low self-esteem and impaired social skills You answered this question correctly. Explanation The core symptoms of ADHD include hyperactivity, impulsiveness, and inattention. Hyperactive children are restless; have difficulty remaining seated when required; and exhibit excessive talking, blurting out answers prematurely, and interrupting others. Inattention is characterized by reduced ability to focus and attention to detail, easy distractibility, and failure to follow through (eg, homework, chores). The primary symptoms of ADHD have a negative impact and can make life difficult for children in school, at work, and in social situations. Symptoms interfere with opportunities to acquire social skills and may also result in rejection and critical judgment by peers. The negative consequences of ADHD include: • Poor self-esteem • Increased risk for depression and anxiety • Increased risk for substance abuse • Academic or work failure • Trouble interacting with peers and adults (Option 1) Children with ADHD are more likely to have a learning disability. Confusion is not a typical clinical finding. (Option 2) Although children with ADHD may appear to be emotionally immature for their age, ADHD is not associated with delayed physical growth. (Option 3) Children with ADHD are not disoriented. ADHD is associated with a range of cognitive impairments, but no single cognitive dysfunction typifies all children with the disorder. Some children have no impairment at all. Educational objective: The diagnosis of ADHD includes the presence of hyperactivity, impulsiveness, and inattention. The negative consequences of the core manifestations include impaired social skills, poor self-esteem, academic or work failure, increased risk for depression and anxiety, and increased risk for substance abuse. Test Id: Question Id: 31965 () The registered nurse is counseling the parent of a child recently diagnosed with attention-deficit hyperactivity disorder (ADHD), combined type. Which statement by the parent requires an intervention? Unordered Options Ordered Response 1. "I should offer a choice between 2 things for my child's clothes or meals." 2. "I will need to advocate for an individualized educational plan for my child." 3. "My child will outgrow this disorder around age 20." 4. "When talking with my child, I should not be multi-tasking." Explanation Symptoms of ADHD usually continue into adulthood; current research indicates that children do not outgrow the condition. However, individuals with ADHD learn to cope with and manage the symptoms and achieve their full potential, leading healthy and satisfying lives. They may move into a condition of being "recovered," but this is usually a dynamic and ongoing state. (Option 1) Children with ADHD are usually overwhelmed and overstimulated when faced with numerous choices. Offering 2 choices will help organize and structure the child's decision-making process. (Option 2) There are legal mandates requiring school-based services and accommodations for children with ADHD. However, some teachers and/or school systems may not be as familiar with these requirements; it is important that parents of children with ADHD advocate for these individualized services. (Option 4) Parents and caregivers should make direct eye contact and focus on their children when giving instructions. Other distractions should be minimized to avoid overstimulation. Educational objective: Two common misunderstandings about ADHD are that children outgrow it as they become adults, and that dietary modifications (eg, restricting additives and/or sugar) will improve or "cure" the symptoms. Neither statement is true. These individuals learn to cope with and manage their symptoms as they grow older, but they do not outgrow ADHD. Test Id: Question Id: 31980 () The nurse on the mental health unit recognizes the use of which defense mechanism when a client leaves a stressful family meeting and immediately begins to verbally abuse a roommate? Unordered Options Ordered Response 1. Compensation 2. Displacement 3. Projection 4. Reaction formation Explanation Displacement, one of many ego defense mechanisms, occurs when a person shifts uncomfortable feelings or impulses about one situation or person to a substitute situation or person deemed acceptable to receive these uncomfortable feelings or impulses. (Option 1) Compensation involves experiencing a perceived deficit in one area and making up for it by overachieving in another. An example is someone not doing well academically who focuses on doing well in sports. (Option 3) Projection involves feeling uncomfortable with an impulse or feeling and easing the anxiety by assigning it to another person. An example is a husband with thoughts of infidelity who then accuses his wife of being unfaithful. (Option 4) Reaction formation involves transforming an unacceptable feeling or impulse into its opposite. An example is a client with cancer who fears dying but behaves in an overly optimistic and fearless manner about his treatment and prognosis. Educational objective: Displacement is an ego defense mechanism that involves transferring uncomfortable feelings, emotions, or impulses about one person or situation to a substitute person or situation. Copyright © UWorld. Test Id: Question Id: 30748 () Which of the following actions would the nurse include in planning care for a client hospitalized for bipolar disorder, acute manic episode? Select all that apply. Unordered Options Ordered Response 1. Assign the client to a private room 2. Choose clothing for the client 3. Have the client be in charge of planning an outing for the unit 4. Have the client join other clients in the dining room for meals 5. Have the client participate in physical exercise with a staff member 6. Include the client in group therapy sessions Explanation In developing a care plan for a client experiencing acute mania, the nurse is aware that an acute manic episode is characterized by the following: • Excessive psychomotor activity • Euphoric mood • Poor impulse control • Flight of ideas, non-stop talking • Poor attention span, distractibility • Hallucinations and delusions • Insomnia • Wearing bizarre or inappropriate clothing, jewelry, and makeup • Neglected hygiene and inadequate nutritional intake The care plan for a client experiencing an acute manic episode includes the following: • Reduction of environmental stimuli o Providing a quiet, calm environment o Limiting the number of people who come in contact with the client o One-on-one interactions rather than group activities o Low lighting • A structured schedule of activities to help the client stay focused • Physical activities to help relieve excess energy • Providing high-protein, high-calorie meals and snacks that are easy to eat • Setting limits on behavior (Option 3) The client is easily distractible and would not be able to focus on planning an activity. (Option 4) The client who is experiencing an acute manic episode needs reduced environmental stimuli. Eating with other clients in the dining room would be too stimulating and could exacerbate psychomotor activity. (Option 6) The client with acute mania is not ready to participate in group activities. Educational objective: The nursing care plan for clients with acute mania includes providing a quiet, structured, non-stimulating environment; engaging the client in one-on-one activities and physical activity; limiting contact with other people; and providing foods of high nutritional value that are easy to eat. Test Id: Question Id: 33456 () The nurse assigned to care for the client with a diagnosis of histrionic personality disorder expects to observe which characteristics and behaviors? Unordered Options Ordered Response 1. Fears abandonment, agreeable, needs constant reassurance 2. Likes to be the center of attention, exaggerated emotional expression, little tolerance for frustration 3. Seems uncomfortable around people, lack of close friends, indifferent to praise or criticism 4. Tries to intimidate others, manipulative, lacks empathy Explanation The nurse should recognize the following characteristics associated with histrionic personality disorder: • Self-dramatizing, exaggerated or shallow emotional expression • Attention-seeking, needs to be the center of attention • Overly friendly and seductive, attempts to keep others engaged • Demands immediate gratification and has little tolerance for frustration An individual with histrionic personality disorder displays these behaviors and characteristics persistently. The signs and symptoms are maladaptive and have a negative impact on the client's social, interpersonal, and occupational life. (Option 1) Clients with dependent personality disorder fear separation and tend to be indecisive and unable to take the initiative. They are often preoccupied with the thought of being left to fend for themselves and want others to assume responsibility for all major decision making. (Option 3) Clients with schizoid personality disorder exhibit social detachment and an inability to express emotion. They do not enjoy close relationships and prefer to be aloof and isolated. (Option 4) Clients with antisocial personality disorder have a pattern of disregard for and violation of the rights of others. They manipulate others for personal gain and lack empathy. Educational objective: Histrionic personality disorder is characterized by persistent attention-seeking behavior and exaggerated emotionality. The client with this disorder demands immediate gratification and has little tolerance for frustration. Test Id: Question Id: 30686 () The home health aide reports to the nurse care manager that the client has been trying to give away possessions. When the nurse asks the client about this behavior, the client says, "With my spouse dead, there's no reason for me to go on." What is the best priority response by the nurse? Unordered Options Ordered Response 1. "Do you have any friends in the building?" 2. "Have you had any thoughts of hurting yourself?" 3. "Tell me more about how you're feeling." 4. "You're not thinking of killing yourself, are you?" Explanation Giving away possessions and making statements such as, "There is no reason for me to go on," are indications of suicidal ideation. The most important nursing action is to perform a suicide risk assessment to determine interventions to ensure the client's safety. Determining if the client has had thoughts of self harm is a priority. The nurse can ask the client direct questions such as, "Do you feel like hurting yourself?" or "Are you thinking about killing yourself?" or "Do you want to die?" During the assessment, it is important for the nurse to create a sense of trust and compassion and engage the client in a nonjudgmental manner. Additional questions that are part of a suicide risk assessment include the following: • Have you thought about how you would kill yourself? • Do you have a plan to kill yourself? • If you were to kill yourself, how would you do it? If the client has a suicide plan, the nurse needs to ask about the details. The risk of a client completing suicide increases when the client has planned for a specific time and place, has chosen a highly lethal method (eg, firearm, hanging), and has chosen circumstances in which there would be little or no chance of interruption. (Option 1) It is important to assess the client's social support system, but it is not the priority assessment. (Option 3) This is not the priority assessment; it is more important to determine if the client is thinking about suicide or has a plan. (Option 4) This is a leading question and implies what the answer should be. Educational objective: A suicide risk assessment is the priority nursing action for a client who expresses thoughts about "not wanting to go on" or "wishing for death" or engages in potential suicidal indicators such as giving away possessions. Asking the client directly about thoughts of hurting or killing oneself is a therapeutic approach and an essential component of the risk assessment. Test Id: Question Id: 30536 () A client recently diagnosed with schizophrenia is hospitalized. The client appears distraught and says to the nurse, "The voices are bad today…they are so angry with me." Which of the following is the best response by the nurse? Unordered Options Ordered Response 1. "Do you need something to help you calm down?" 2. "Don't pay any attention to the voices. Let's go into the dayroom." 3. "The voices are not real. Tell them to go away." 4. "What are the voices saying to you?" Explanation The priority nursing action is to explore the content of the hallucinations. This client may be experiencing command auditory hallucinations that could lead to self-directed or other-directed injury and harm. After the content of the hallucinations has been explored, implementing an intervention may be necessary to reduce the potential for violence. Hallucinations are false sensory perceptions that have no external stimuli. They can occur in any of the 5 senses. Auditory hallucinations are the most common, followed by visual, tactile (touch), olfactory (smell), and gustatory (taste). Additional ways to deal with hallucinations include the following: • Telling the client that you know they are real to the client but that you do not hear the voices (or see the vision, feel the sensation) • Not arguing with or challenging the client about the hallucinations • Directing the client to a reality-oriented topic of conversation or activity (Option 1) An antianxiety medication may be needed if the voices are causing this client to become increasingly distressed. Assessment is needed before choosing this option. (Option 2) This choice dismisses this client's concerns about the nature of the voices. (Option 3) Telling the voices to "go away" (voice dismissal) is a technique that some clients find effective in management of hallucinations. It is not the priority nursing action in this client. Educational objective: It is important for the nurse to initially explore the content of a client's hallucinations to assess the risk for harm and/or injury and determine appropriate interventions. The nurse can tell the client that the nurse knows the voices are real to the client but are not heard by the nurse. The client with hallucinations should be directed to reality-oriented activities rather than to further discussion of the content of the hallucinations. Test Id: Question Id: 30793 () A client is receiving nasogastric tube feedings as nutritional rehabilitation for anorexia nervosa. After a weigh-in, the client learns of gaining 2 lb (0.9 kg) and says to the nurse, "See what your force feeding has done to me? I'm fatter and uglier than ever." What is the best action by the nurse? Unordered Options Ordered Response 1. Have the client keep a journal and write about feelings 2. Initiate one-on-one supervision of the client during feedings 3. Remind the client that gaining weight means being able to go home 4. Say that the client is not fat and ugly Explanation Nutrition support (enteral tube feedings and total parenteral nutrition) is usually reserved for clients with anorexia nervosa who are severely ill and/or have not responded to oral nutritional therapy. Such clients are at high risk for medical complications from anorexia nervosa, including death. Criteria for nutrition support include: • Severe weight loss that is life threatening • Client's unwillingness to adhere to a treatment plan of oral feedings The priority nursing actions for this high-risk client include interventions to meet physiological and safety needs. Providing one-on-one supervision during the tube feeding will ensure that the client is actually receiving the feeding and prevent the client from stopping the feeding and/or pulling out the nasogastric tube. During the one-on-one contact with the client, the nurse can promote a therapeutic and trusting relationship with the client by: • Being honest and accepting of the client • Presenting the reality of the condition • Acknowledging the client's feelings of loss of control and anger • Encouraging the client to express feelings and fears (Option 1) This is an appropriate intervention for a client with anorexia nervosa. Feelings related to lack of control are an underlying problem for these clients, who use food as a way to deal with them. Keeping a diary or journal of feelings will help the client recognize and express them more clearly. However, this is not the priority nursing action. (Option 3) This may be a true statement; clients with anorexia nervosa are usually discharged to out-patient follow-up and treatment or to a residential treatment facility once an acceptable weight gain has been achieved and maintained. However, this is not the priority nursing action. (Option 4) Clients with anorexia nervosa have a distorted body image and a morbid fear of being overweight; they perceive themselves as "fat and ugly" even when they are emaciated. Saying that the client is not "fat and ugly" will not change this perception. Educational objective: The priority nursing care for a client with anorexia nervosa is nutritional rehabilitation and prevention of medical complications, including death. Clients who are severely ill and/or resistant to oral refeeding may require nutrition support with intense monitoring to achieve adequate caloric intake and weight gain. Test Id: Question Id: 30682 () A client with major depressive disorder has been hospitalized for 3 days. The night nurse reports that the client has been unable to go to sleep until late at night. The client gets up, paces the hallway, wrings her hands, and appears teary. Which interventions should be included in the client's nursing care plan? Select all that apply. Unordered Options Ordered Response 1. Arrange for the client to receive 20 minutes of natural sunlight each day 2. Encourage the client to take naps during the day to make up for lost sleep 3. Have the client engage in strenuous physical exercise just before bedtime 4. Serve the client a glass of warm milk in the evening 5. Spend time with the client in a quiet environment just before bedtime 6. Tell the client to take a warm bath before going to bed Explanation Sleep disturbances are part of the diagnostic criteria for major depressive disorder. Clients may experience insomnia (early in the night, in the middle of the night, or in the early morning hours) or hypersomnia. A number of pharmacological agents are used to treat insomnia; however, long-term treatment with medication alone is not necessarily the best approach. Strategies for improving sleep hygiene include the following: • Staying up during the day and avoiding naps • Engaging in physical activity or exercise during the day, preferably at least 5 hours before bedtime • Receiving at least 20 minutes of natural sunlight each day, ideally in the morning (natural sunlight is associated with improved sleep patterns) • Avoiding coffee or other caffeinated beverages after noon • Avoiding alcohol and/or smoking at bedtime • Dealing with or thinking about one's concerns or issues prior to bedtime, letting go of one's worries before going to bed • Participating in a relaxing activity, such as a warm bath, reading, or listening to soft music, prior to bedtime • Decreasing environmental stimuli in the bedroom; making sure the room is dark, cool, and quiet • Avoiding heavy meals or large amounts of fluids at bedtime • Drinking a cup of warm milk or eating a small amount of carbohydrates before bedtime (milk contains tryptophan, which promotes sleepiness; carbohydrates aid in the release of serotonin, which promotes relaxation) (Option 2) Napping during the day interferes with normal sleep patterns. (Option 3) Exercising right before going to bed increases brain metabolic activity and wakefulness. Educational objective: Nonpharmacological strategies for improving sleep hygiene include exercising during the day, engaging in a relaxing activity before bedtime, dealing with worries at a set time of the day, providing a relaxing sleep environment, avoiding naps during the day, avoiding caffeine after noon, and drinking a warm cup of milk before bedtime. Test Id: Question Id: 30571 () The nurse is caring for a client with schizophrenia who has been experiencing visual hallucinations. The client says in a trembling voice, "There's a bad man standing over there in the corner of my room." What is the best response by the nurse? Unordered Options Ordered Response 1. "I know you are frightened, but I do not see a man in your room." 2. "I'll make the bad man go away." 3. "Let's go into the dayroom and play checkers." 4. "Your illness is making you hallucinate." Explanation An important step toward self-management of hallucinations is for the client to recognize that the hallucinations are not real. When a client is experiencing hallucinations, the nurse needs to reinforce reality and acknowledge how the client may be feeling. The nurse can point out his/her own perceptions without denying the client's experience. It is nontherapeutic to argue with or challenge the client about the hallucination, saying, for example, "How could a man get into your room? This is a locked hospital unit." Examples of additional therapeutic responses to a client who is experiencing hallucinations include the following: • "I don't see anything, but I understand that what you are seeing may be very upsetting to you." • "I understand that you are worried about the voices you are hearing. They are a part of your disease and not real." • "I know the voices seem real to you and may be scary. I do not hear the voices." (Option 2) This response reinforces the hallucination and does not present reality to the client. (Option 3) This response ignores what the client is experiencing and does nothing to reduce the client's feeling of discomfort. (Option 4) This response provides an explanation for the client's experience but does not acknowledge the client's feelings or reinforce reality. Educational objective: The most therapeutic response to a client experiencing hallucinations presents reality and acknowledges how the client may be feeling. This approach promotes self- management by helping the client recognize that the hallucinations are not real. Test Id: Question Id: 30922 () A client with generalized anxiety disorder is referred to outpatient mental health department for cognitive behavioral therapy (CBT). The CBT includes which interventions and strategies? Select all that apply. Unordered Options Ordered Response 1. Desensitization to a specific stimulus or situation 2. Discussing the interpersonal difficulties that have led to the client's psychological problems 3. Helping the client develop insight into the psychological causes of the disorder 4. Relaxation techniques 5. Self-observation and monitoring 6. Teaching new coping skills and techniques to reframe thinking Explanation Cognitive behavioral therapy (CBT) can be effective in treating anxiety disorders, eating disorders, depressive disorders, and medical conditions such as insomnia and smoking. These types of disorders are characterized by maladaptive reactions to stress, anxiety, and conflict. CBT requires that the client learn the skill of self- observation and to apply more adaptive coping interventions. CBT involves 5 basic components: • Education about the client's specific disorder • Self-observation and monitoring - the client learns how to monitor anxiety, identify triggers, and assess the severity • Physical control strategies – deep breathing and muscle relaxation exercises • Cognitive restructuring – learning new ways to reframe thinking patterns, challenging negative thoughts • Behavioral strategies – focusing on situations that cause anxiety and practicing new coping behaviors, desensitization to anxiety-provoking situations or events (Option 2) This describes interpersonal psychotherapy. (Option 3) This describes psychodynamic or psychoanalytic therapy. Educational objective: CBT teaches clients to reframe their thought processes and develop new adaptive approaches for coping with anxiety, stress, and conflict. CBT requires that the client learn about the disorder and engage in self-observation and monitoring, relaxation techniques, desensitization activities, and changing negative thoughts. Test Id: Question Id: 33434 () The nurse assesses a client who is suspected of using illicit substances. Which assessment findings would indicate heroin withdrawal? Select all that apply. Unordered Options Ordered Response 1. Bone and muscle pains 2. Bradycardia 3. Dilated pupils 4. Drowsiness 5. Rhinorrhea Explanation When a person has used a substance heavily for a long time and it is stopped or reduced, a set of physiological symptoms occurs as the amount of the substance in the system decreases. Heroin is a commonly abused opioid drug. Generalized myalgias, abdominal cramps, diarrhea, piloerection (goose bumps), and pupillary dilation are consistent with opioid withdrawal. Other common features include nausea, vomiting, frequent yawning, restlessness, rhinorrhea, and increased lacrimation. (Options 2 and 4) The heart rate would be rapid and the client would have insomnia and anxiety. Mental status may be impaired in acute opioid intoxication but is usually normal in withdrawal. Educational objective: Manifestations of heroin withdrawal include myalgias, arthralgias, abdominal cramps, diarrhea, piloerection (goose bumps), and pupillary dilation. Frequent yawning, restlessness, rhinorrhea, and increased lacrimation are also common. Test Id: Question Id: 30300 () Which statement made by the nurse during a therapy session demonstrates a need for further instruction regarding effective therapeutic communication techniques? Unordered Options Ordered Response 1. "I don't understand what you mean. Can you give me an example?" 2. "It is doubtful the president is out to get you." 3. "Tell me more about the day your child died." 4. "Why did you get so angry when she ignored you?" Explanation Therapeutic communication allows the nurse to develop a healthy interpersonal relationship with the client. A "why" question is often avoided as it is viewed negatively by clients and can make them feel defensive about their choices or emotions (Option 4). (Option 1) Asking for an example is asking for clarification and is considered a therapeutic communication technique. (Option 2) Voicing doubt is a therapeutic communication technique that allows the nurse to dispel misconceptions or delusions without directly confronting the client's beliefs. (Option 3) Exploring is a therapeutic communication technique that encourages the client to discuss relevant situations and feelings. If the client chooses not to share information, the nurse should respect that decision and not probe further. Educational objective: For people who are anxious or overwhelmed, a "why" question asked by the nurse is often interpreted as being critical, judgmental, and intrusive. These feelings are damaging to the development of the nurse-client relationship and therapeutic communication. Test Id: Question Id: 31289 () The client had surgery for possible cancer. The positive biopsy result is back in the medical record, but the client has not been told that the biopsy showed malignancy. The client asks the nurse, "Am I going to die?" What is the best way for the nurse to initially handle the situation? Unordered Options Ordered Response 1. "Everyone will die one day, but good treatment is available for most cancers today." 2. "I can understand your anxiety about the situation. Let me call your health care provider (HCP)." 3. "Share with me your thoughts and feelings about the situation." 4. "The biopsy result came back as malignant, but that doesn't mean the cancer is not treatable." Explanation The nurse must first assess the client's knowledge and feelings about the situation. Use of therapeutic communication techniques, including listening, reflection, and focusing allow the nurse to determine the client's needs at that time. Often, the client is just seeking an empathetic listener. (Option 1) Under the ethical principle of veracity, the nurse should not lie or offer false reassurance. It is unclear at this time what the prognosis or treatment options are for this client, and automatic responses (eg, "everyone will die one day") and false reassurance (eg, "good treatment is available for most cancers today") are types of nontherapeutic communication. (Option 2) Although contacting the HCP may be necessary, the nurse should first explore the client's thoughts and feelings to determine the client's current needs. (Option 4) The news of the positive biopsy result should be given by the HCP so that factual information as well as prognosis and treatment options can be provided at that time. There is no ethical or legal obligation for the nurse to reveal a client's results the moment the results are available. Educational objective: When asked by a client about results or dying, respond by assessing the client's understanding of the situation and/or feelings about the topic using therapeutic communication skills. Test Id: Question Id: 33469 () The nurse is caring for an intubated client whose oxygen saturation begins to drop. What action should the nurse take first? Unordered Options Ordered Response 1. Auscultate lung sounds bilaterally 2. Hyper-oxygenate with 100% oxygen 3. Manually ventilate with bag valve mask 4. Suction the endotracheal tube Explanation A drop in oxygen saturation signifies a problem with ventilation. When an artificial airway is present, the nurse should assess the client to determine the cause of hypoventilation. Auscultating lung sounds is the first step and quickest intervention to confirm proper tube placement. It is not uncommon for the tube to become displaced in the hypopharynx, which would not allow proper ventilation. Another important complication is pneumothorax, which can cause hypotension and a drop in oxygen saturation. Lung auscultation would help diagnose this as well. (Option 2) Hyper-oxygenating would not increase ventilation if the tube is not in proper position or if the client has a pneumothorax. (Option 3) The first step is to confirm tube placement. Manually ventilating through a displaced tube would produce no better results than use of the ventilator. (Option 4) Mucus plugs are a common cause of decreased oxygen saturation in the intubated client. There are, however, specific symptoms associated with this problem, including secretions backing up in the tube and high-pressure ventilator alarms. Although this client may still need suctioning even if these symptoms are not present, auscultating lung sounds is necessary to confirm tube placement before suctioning. Suctioning via a displaced tube could cause additional damage to the client's airway. Educational objective: Proper placement of the endotracheal tube is essential for adequate ventilation in intubated clients. If the tube becomes displaced in the hypopharynx, hypoxemia can result. Confirming the presence of equal breath sounds bilaterally via auscultation is an important initial nursing intervention. Test Id: Question Id: 30795 () A client hospitalized for anorexia nervosa has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which nursing actions are appropriate for promoting weight gain in this client? Select all that apply. Unordered Options Ordered Response 1. Determine minimum goals for daily caloric intake and weekly weight gain 2. Do not allow client to make food choices 3. Restrict privileges if weight loss occurs 4. Reweigh client on request 5. Set limits on physical activities 6. Sit with client during meals and discuss nutritional value of served foods Explanation Clients who need hospitalization for anorexia nervosa will commonly have protein- energy malnutrition and severe weight loss within a short period. Weight gain and improvement in nutritional intake must be achieved before the client can be discharged to outpatient follow-up and treatment. Nursing care strategies for promoting intake and weight gain include: • Determining minimal caloric intake for weight gain and keeping a daily record of consumed calories and protein o If the client is unable to consume adequate oral nutrition, tube feedings may be necessary • Establishing a goal for weekly weight gain o Weight gain of 2-3 lb (0.9-1.36 kg/wk) is an appropriate goal for most clients; anything higher would place the client at risk for re-feeding syndrome due to excessive caloric intake. o Clients should initially be weighed daily in the morning, at the same time, on the same scale, in the same clothing, after voiding and before meals o The frequency of weigh-ins can be reduced once the client has established a pattern of adherence to the treatment plan, as evidenced by weight gain o Weigh-ins should be done in a matter-of-fact, non-judgmental manner • Allowing clients to make food choices when possible to give a sense of control o Low-calorie food selections must be monitored and limited • One-on-one supervision during meals to ensure the client consumes food and does not pocket it or throw it away; discussions about food should be limited to minimize the client's preoccupation with food. • Allowing privileges only if the client adheres to the treatment plan, as evidenced by weight gain o Setting limits avoids power struggles, provides structure, and ensures client safety • Monitoring and setting limits on physical activity (Option 2) Clients should be allowed to make food choices when feasible. (Option 4) Reweighing on request will reinforce the client's preoccupation with weight. (Option 6) Discussing the nutritional value of foods will reinforce the client's preoccupation with food. Educational objective: Strategies to improve nutritional intake and promote weight gain in a client with anorexia nervosa include setting goals for daily caloric intake and weekly weight gain, allowing the client to make food choices, monitoring intake, setting limits on physical activity and exercise, basing privileges on treatment adherence, and maintaining a matter-of-fact, nonjudgmental approach toward weight and food-related behaviors. Test Id: Question Id: 30217 () A nurse performs the initial assessments for 4 assigned clients. The nurse identifies which client as being at greatest risk for the development of delirium? Unordered Options Ordered Response 1. 32-year-old client with gastroenteritis 2. 55-year-old client with coronary artery disease, 4 days post coronary bypass surgery 3. 60-year-old client with type II diabetes, 2 months post bilateral above-knee amputations 4. 80-year-old client with chronic obstructive pulmonary disease, chronic respiratory failure, and urosepsis Explanation Major predisposing factors for the development of delirium in hospitalized clients include: 1. Advanced age 2. Underlying neurodegenerative disease (stroke, dementia) 3. Polypharmacy 4. Coexisting medical conditions (eg, infection) 5. Acid-base/arterial blood gas imbalances (eg, acidosis, hypercarbia, hypoxemia) 6. Metabolic and electrolyte disturbances 7. Impaired mobility - early ambulation prevents delirium 8. Surgery (postoperative setting) 9. Untreated pain and inadequate analgesia Client 4 has 4 predisposing risk factors: advanced age, acidosis and hypoxemia associated with chronic respiratory failure, and sepsis. This client is at greatest risk for developing delirium. (Option 1) Although gastroenteritis with possible dehydration and electrolyte imbalances predisposes to delirium, this client is not at greatest risk. (Option 2) Although surgery, especially that requiring cardiac bypass, predisposes to delirium, this client is not at greatest risk. Early ambulation and adequate pain control prevent the development of delirium in the postoperative setting. (Option 3) Although coexisting medical conditions, such as diabetes mellitus and impaired mobility, predispose to delirium, this client is not at greatest risk. Educational objective: Risk factors for hospital-induced delirium include advanced age, underlying neurodegenerative disease, infections, medical illness, surgery, impaired mobility, and inadequate pain control. Test Id: Question Id: 33836 () The acute care clinic nurse administers a prescribed narcotic for a client with renal colic and then discharges the client without ensuring that the client has a designated driver. The client is subsequently involved in a motor vehicle accident causing injury to self and others. Which ethical principle did the nurse violate? Unordered Options Ordered Response 1. Autonomy 2. Nonmaleficence 3. Paternalism 4. Veracity Explanation The nurse violated the ethical principle "nonmaleficence" (ie, do no harm). It is rare to see a nurse inflict intentional harm. However, problems do occur due to unintentional harm, which is usually a result of poor clinical judgment. Beneficence is a nurse's duty to promote good and do what is best for the client. (Option 1) Autonomy is allowing the clients to choose the direction of their care. This is accomplished with advanced directives along with informed consent and choices regarding proposed treatments. (Option 3) Paternalism is a type of beneficence whereby clients are treated as children. The nurse claims to know what is best for the client and coerces the client to act as the nurse wishes without considering the client's autonomy. (Option 4) Veracity refers to the duty to tell the truth. This principle should always be applied to client care and documentation. Educational objective: Nonmaleficence is the ethical principle of doing no harm. All nurses must exercise sound clinical judgment to prevent harm, even if it is unintentional, to their clients. Test Id: Question Id: 32005 () The nurse reviews the social history of an adolescent client and understands that which behaviors support a diagnosis of conduct disorder? Select all that apply. Unordered Options Ordered Response 1. Blames voices when confronted about misbehavior 2. Fluctuates moods between depression and elation 3. Frequently ignores the curfew established by parents 4. Inserted thumbtacks into the feet of a neighbor's dog 5. Vandalized a painting in a local art museum You answered this question incorrectly. Correct answer is: 4,5 Explanation Conduct disorder is diagnosed when children and adolescents consistently demonstrate behaviors that violate the rights of others. The behaviors are more extreme than those socially acceptable for the child's or adolescent's age. Cruelty to animals and destruction of the property of others are diagnostic of conduct disorder (Options 4 and 5). (Option 1) Clients with schizophrenia, manic or depressive illness, or who are under the influence of a hallucinogenic substance experience auditory hallucinations. Blaming misbehavior on auditory hallucinations does not support the diagnosis of conduct disorder. (Option 2) Adolescents diagnosed with bipolar disorder experience recurrent episodes of mania (elevated mood) and depression. Fluctuating mood does not support the diagnosis of conduct disorder. (Option 3) Children and adolescents with oppositional defiant disorder manifest as defiant and display angry, argumentative, and moody behaviors; however, they do not violate the basic rights of others. Defiant behavior (eg, ignoring parents' rules) does not support the diagnosis of conduct disorder. Educational objective: Conduct disorder involves behaviors that violate social norms and the rights of others. Cruelty to animals and destruction of the property of others are diagnostic behaviors associated with conduct disorder. Test Id: Question Id: 33390 () The mental health nurse engaged in dialogue with a client would recognize transference when the client makes which statement? Unordered Options Ordered Response 1. "I can pretend to have feelings; how would you know the difference?" 2. "My roommate doesn't seem to like me very much." 3. "Sharing my thoughts with you will be difficult; you remind me of my sister." 4. "The people who work here do not seem genuine." Explanation The nurse-client relationship is the basis of quality nursing treatment approaches in mental health. It should have clear boundaries that allow for the client to examine feelings and treatment issues. The nurse's needs are clearly separated from the client's needs. However, roles can become blurred when transference and countertransference are not recognized. The act of a client unconsciously displacing (transferring) feelings and behaviors related to a person in the client's past onto the nurse is known as transference. The nurse unknowingly displacing feelings and behaviors about someone in the nurse's past onto the client is known as countertransference. These phenomena disrupt the therapeutic nurse-client relationship. (Options 1, 2, and 4) These client statements do not represent transference. Educational objective: It is important for the nurse to recognize transference in order to maintain a therapeutic nurse-client relationship. Copyright © UWorld. All rights reserved. Test Id: Question Id: 30730 () The 17-year-old child of a client being treated for alcoholism tells the nurse that the parent's disease and behavior have taken a toll on the whole family; the child is especially concerned about a 13-year-old sibling who is having trouble in school. The nurse should provide the child with information about what resource? Unordered Options Ordered Response 1. Adult Children of Alcoholics (ACOA) 2. Alateen 3. Alcoholics Anonymous (AA) 4. National Association for Children of Alcoholics (NACOA) Explanation Alcoholism can have profound, negative effects on family members. The term "co- dependent" is used to define family members who have experienced physical or emotional abuse or other pathological conditions as the result of living with someone who is a substance abuser. Co-dependent family members may have a sense of powerlessness, loss of self-esteem, and neglects their own needs to meet the demands of others. Co-dependent persons may engage in their own dysfunctional behavior. There are many resources and self-help groups that provide support to alcohol-addicted individuals and their co-dependents. These include the following: 1. AA - the major self-help organization that provides help and support to individuals who want to stop drinking. AA uses a 12-step approach that provides guidelines on attaining and maintaining sobriety. 2. ACOA - a 12-step, 12-tradition program that provides assistance to adults who grew up in homes that were dysfunctional due to alcoholism 3. Al-Anon - provides help for spouses and significant others of alcoholics to share their own personal experiences and coping strategies 4. Alateen - part of the Al-Anon Family Groups; it provides support to teenagers whose lives have been affected by someone else's drinking 5. NACOA - raises public awareness of the effect of alcoholism on children and family members through leadership in public policy, advocating for prevention services, and providing on-line educational resources 6. Families Anonymous - helps friends and families whose lives have been affected by substance abuse of any kind (Option 1) This organization is for adults. (Option 3) AA provides help to the individual with alcoholism. (Option 4) NACOA provides educational resources but no in-person support services. Educational objective: Alcoholism affects the whole family. Alcoholics Anonymous provides help to the individual who has alcoholism. Alateen provides support to teenagers whose lives have been affected by someone else's drinking. Al-Anon provides help for spouses and significant others of alcoholics. Test Id: Question Id: 30524 () A client with a 20-year history of schizophrenia is hospitalized. The client appears visibly upset, approaches the nurse, and says in a shaky voice, "I can't find my headband. I can't find my headband. The oil is going to leak out of the crack in my head." What is the best response by the nurse? Unordered Options Ordered Response 1. "How long has the oil been leaking from your head?" 2. "Let's go back to your room and look for your headband together." 3. "There is no oil coming out of your head." 4. "You are going to miss breakfast if you do not go into the dining room." Explanation The client, while delusional, is exhibiting signs of anxiety. The priority action for the nurse is to intervene in a manner that will assist in reducing the client's unease. The headband is part of the client's delusional system; it is highly likely that the client will continue to be apprehensive until the headband or substitute is found. Offering to help the client look for the headband conveys a sense of caring and helps establish a trusting relationship. Once the client has calmed down, the nurse will minimize any conversation about the "crack" and the "oil" and can direct the client to reality-oriented activities. Delusions are fixed, false beliefs that are accepted by the client as real and cannot be changed by logic, reason, or persuasion. Categories of delusions include the following: • Persecutory – client thinks others are "out to get me" • Ideas of reference – common events refer specifically to the client • Grandiose – client has the perception of special importance or powers that are not realistic • Somatic – false ideas about bodily functioning Nursing interventions include the following: • Not arguing or challenging the belief • Reinforcing reality by talking about and encouraging the client to participate in real events. The nurse should not delve into or have long conversations about the delusional belief system. (Option 1) This response focuses on the delusional content and is not therapeutic. It does not help alleviate the client's anxiety. (Option 3) Challenging the delusional content is not therapeutic and will not change the client's belief. (Option 4) This statement does not help reduce the client's anxiety. Educational objective: The priority nursing action for a client exhibiting anxiety is to intervene in a manner that helps make the client feel more at ease. Delusions are fixed, false beliefs; challenging a client's delusional content system will increase the client's anxiety and will not change the client's beliefs. Test Id: Question Id: 30828 () A client who was suddenly overwhelmed with an intense fear that something terrible was going to happen is brought to the emergency department by the spouse after they were out at dinner. The client is now shaking and has shortness of breath and heart palpitations. What is the priority nursing action? Unordered Options Ordered Response 1. Encourage the client to perform deep breathing exercises 2. Explore possible reasons for the episode 3. Place the client in a private room and tell the client to relax 4. Stay with the client Explanation This client is experiencing the symptoms of a panic attack and should not be left alone. The priority nursing action is to stay with the client to offer support and reassurance that the client is safe and secure. Additional nursing actions while the client is experiencing panic symptoms include: • Maintaining a calm, matter-of-fact approach • Speaking calmly and using simple, clear words and phrases when providing information on emergency department procedures • Placing the client in a room with as little stimuli as possible • Administering an anti-anxiety medication such as a benzodiazepine (per health care provider prescription) • Having the client breathe into a paper bag if hyperventilation is a problem (Option 1) Breathing into a paper bag, not deep breathing exercises, is the best strategy for relieving hyperventilation. (Option 2) Discussing the reasons for the panic attack is not appropriate while the client is still symptomatic. Once the client has calmed down, the nurse can discuss reasons for the attacks, evaluate stressors in the client's life, and assist the client in developing prevention strategies. (Option 3) A private room is appropriate; however, just telling a client to relax is not helpful. Educational objective: The priority nursing action for the client experiencing symptoms of a panic attack is for the nurse to stay with the client in a calm environment and offer support and reassurance that the client is safe and secure. Test Id: Question Id: 32806 () A client with moderate Alzheimer disease is started on memantine. In evaluating the effectiveness of this medication, the registered nurse should assess the client for which of the following? Unordered Options Ordered Response 1. Improved ability to perform activities of daily living 2. Indications that disease progression has stopped 3. Rapid improvement in cognitive functioning 4. Reversal of the disease Explanation Memantine is used to ease the symptoms of moderate to severe Alzheimer disease (AD), thereby improving the quality of life for clients and caregivers. Memantine is an N- methyl-D-aspartate (NMDA) antagonist that works by binding to NMDA receptors, blocking the brain's NMDA glutamate pathways, and protecting brain cells from overexposure to glutamate (excess levels of glutamate contribute to brain cell death). Clients with moderate to severe AD may experience improvement in: • Cognition – memory, thinking, language • Daily functioning – dressing, bathing, grooming, eating • Behavioral problems – agitation, depression, hallucinations (Option 2) Memantine delays but does not stop progression of some symptoms of moderate to severe AD. (Option 3) Memantine does not cause rapid improvement of cognitive functioning; it usually takes weeks or months before such improvement is noticeable. (Option 4) Memantine does not reverse the degenerative process of AD. Educational objective: Memantine is a medication used in the treatment of moderate to severe Alzheimer disease (AD). It slows the progression of AD symptoms, and improvement may be seen in the client's behavior, cognitive functioning, and ability to perform activities of daily living. Test Id: Question Id: 30729 () A client with obsessive-compulsive disorder (OCD) has been cleaning a bathroom for most of the morning. When the roommate demands that the client leave the bathroom so that the roommate can shower, the client becomes angry and says, "You can't make me leave, everything is still dirty." What is the best nursing action? Unordered Options Ordered Response 1. Engage other staff members to remove the client from the bathroom 2. Give a reminder that the client has been cleaning the bathroom for 1½ hours and it is time to take a break 3. Tell the client that the bathroom is very clean and that this behavior is unreasonable 4. Tell the roommate to use the shower in another room Explanation Clients with OCD engage in rituals and behaviors that help reduce the anxiety or stress rooted in their obsessions (recurrent thoughts, impulses, or images that cause notable distress). If the ritual is interrupted, the client will experience increased anxiety. A client with compulsive behavior often does not realize the amount of time or how many times the same activity has been performed. By providing reflective feedback about the client's behavior, the nurse is acknowledging the behavior in a nonjudgmental manner. The nurse should also help the client become involved in other activities and problem-solving skills. (Option 1) Engaging other staff members to remove the client from the bathroom is confrontational and will increase the client's and roommate's anxiety; this approach is not necessary or therapeutic. (Option 3) Pointing out that the bathroom is clean does not change the client's obsessive thoughts. Saying that the client's behavior is unreasonable conveys a message of disapproval and would increase the client's anxiety. (Option 4) Telling the roommate to use a different bathroom allows the client to continue the ritualistic behavior, is non-therapeutic, reinforces the behavior, and avoids the issue. Educational objective: Clients with OCD engage in rituals and activities that help reduce the anxiety associated with unacceptable thoughts, images, and impulses. Therapeutic approaches to a client with OCD include pointing out the amount of time the client has spent performing an activity and redirecting the client to another activity. Test Id: Question Id: 32805 () The daughter of an 80-year-old client recently diagnosed with Alzheimer disease says to the nurse, "I can anticipate getting this disease myself at some point." What is the best response by the nurse? Unordered Options Ordered Response 1. "Have you suffered any recent head trauma?" 2. "If you modify your lifestyle, you can reduce your risk of familial Alzheimer disease." 3. "It is good that you recognize this now so you can plan for your future care." 4. "Not necessarily. The strongest known risk factor for Alzheimer disease is age." Explanation Alzheimer disease (AD) is most likely caused by a combination of genetic, environmental, and lifestyle factors. However, according to the National Institutes of Health, the strongest known risk factor for late-onset AD is advancing age. Most clients with AD receive the diagnosis after age 60. The chance of developing AD doubles about every 5 years after age 65; at age 85, the risk for developing AD is 50%. In a very rare form of AD known as familial AD (autosomal dominant AD), multiple generations are affected. Signs and symptoms may appear during early to middle adulthood, and the diagnosis is made before age 60. (Option 1) Research indicates that serious head injury increases the risk of developing AD in the future; however, advancing age is the strongest and most important risk factor. (Option 2) Although some research suggests an association between modifiable lifestyle factors (ie, diet, exercise, smoking) and a reduced risk for late-onset AD, early- onset familial AD is caused by a gene mutation. (Option 3) There is no indication that the client has true familial AD. The most significant risk factor for the client's daughter is advancing age. Educational objective: The development of Alzheimer disease (AD) is influenced by a combination of genetic, lifestyle, and environmental factors. The most significant and strongest risk factor for late-onset AD is advancing age. Test Id: Question Id: 30926 () Which clinical manifestations would the nurse identify with severe anorexia nervosa? Select all that apply. Unordered Options Ordered Response 1. Amenorrhea 2. Fluid and electrolyte imbalances 3. Heat intolerance 4. Presence of lanugo 5. Refusal to exercise 6. Weight loss of 25% below normal weight Explanation Anorexia nervosa is an eating disorder common among adolescents and young adults. Clinical manifestations of anorexia nervosa include: 1. Fear of weight gain – clients resort to self-induced vomiting, extensive dieting, and intense exercise resulting in excessive weight loss (<85% expected weight). Clients who self-induce vomiting may experience enlargement of the salivary glands and erosion of tooth enamel. 2. Fluid and electrolyte imbalance – excessive vomiting can cause hypokalemia and metabolic alkalosis 3. Amenorrhea – clients are often amenorrheic due to decreased body fat (low estrogen) 4. Decreased metabolic rate – severe weight loss results in hypotension, bradycardia, decreased body temperature, and cold intolerance 5. Lanugo (fine terminal hair) can be seen in extreme cases Manifestations of anorexia nervosa will resolve after the weight loss is corrected, although the recovery process can take several months. (Option 3) Anorexia nervosa manifests as cold intolerance. (Option 5) Anorexia nervosa manifests as lengthy and vigorous exercise. Educational objective: The clinical manifestations of anorexia nervosa include extreme weight loss, amenorrhea, bradycardia, cold intolerance, dry skin, and lanugo. Life-threatening complications, such as cardiac arrhythmias associated with hypokalemia, may develop Test Id: Question Id: 30535 () A client who was placed in restraints appears in the hallway an hour later and states, "I'm Houdini.… I can get out of anything. There could be trouble now." Which of the following is the best response to this client? Unordered Options Ordered Response 1. "How are you feeling now?" 2. "How did you manage to get out of the restraints?" 3. Say nothing but signal to other staff that assistance is needed 4. "What kind of trouble are you thinking about?" Explanation In this situation, the priority nursing action is to quickly and calmly assess this client's present risk for violence before implementing an intervention. This client's statement, "There could be trouble now," has multiple possible meanings (eg, Is the nurse "in trouble" as the restraints may not have been applied properly? Are the other clients in the unit "in trouble" as this client is out of restraints? Is this client "in trouble" due to thoughts of self-harm?). Seeking clarification of this client's statement is a therapeutic communication technique that will help the nurse determine the next steps in providing care. Mechanical restraints may be necessary only as a last resort for a client at high risk for violence, self-directed or other-directed. Clients placed in restraints must be observed and monitored frequently for: • Assisting with hydration, elimination, and positioning • Ensuring that circulation is not compromised • Determining readiness for removal of restraints (Option 1) It is important to ask this client about current feelings. However, in this situation, the priority is to clarify this client's statement. (Option 2) This statement is immaterial; it is important to assess this client's current status. (Option 3) Assistance from another staff member may be necessary if this client is still at high risk for violence; this client needs to be assessed first. Educational objective: A client at high risk for violence, self-directed or other-directed, may need to be placed in restraints as a last resort. Frequent monitoring and assessment through observation and use of therapeutic communication techniques will help determine if a client is ready to have restraints removed. Test Id: Question Id: 31961 () A client states, "I just don't know what to do about this situation with my parents," and the nurse replies, "I'm sure you will do the right thing." Which summary is true regarding the nurse's response? Unordered Options Ordered Response 1. The nurse has encouraged exploration of the client's situation 2. The nurse has shown interest in the client's concerns 3. The response conveys empathy toward the client and promotes self-confidence 4. The response devalues the client's feelings and gives false reassurance Explanation The nurse has used a nontherapeutic communication technique known as "giving reassurance" or "giving false reassurance." A nurse who does not acknowledge a client's feelings and gives the impression that there is nothing to worry about has devalued the client's concerns. This technique serves to block a therapeutic conversation as the client may feel that the verbalization of additional concerns or feelings will also be devalued. (Option 1) The nurse has not encouraged exploration of this client's feelings and options. This could have been done by using any one of several therapeutic communication techniques (eg, reflecting, focusing, exploring). An appropriate response by the nurse, such as stating, "Tell me what concerns you have," would have facilitated communication with the client. (Option 2) The nurse has shown no interest in the client's concerns; instead, the nurse should show interest, be available, and have a conversation with the client (eg, "I will stay and listen to your concerns"). (Option 3) The nurse has not conveyed empathy (attempting to understand and share the feelings behind a client's actions and words). An empathetic nurse might say, "This must be hard for you," or, "I understand you are upset." Educational objective: The nurse must learn to use effective therapeutic communication skills to enhance the development of a trusting and therapeutic nurse-client relationship. Test Id: Question Id: 31082 () The spouse brings a client to the emergency department due to erratic behavior and expressions of despair. The emergency department is extremely busy with many clients. When the triage nurse asks if the client feels suicidal now, the client shrugs the shoulders. What initial action should the triage nurse take? Unordered Options Ordered Response 1. Ask the client to make a verbal contract to not harm self 2. Document that the client is not currently suicidal 3. Place the client in an inside hallway with one-on-one observation 4. Return the client to the waiting room with the spouse Explanation Any client who cannot definitively say that currently he/she is not suicidal should be considered a "yes" and appropriate protective measures should be instituted to prevent suicidal actions. The client is under the hospital's care and the department must assume responsibility for the client's safety. Placing the client in an inside hallway can prevent the client from running outside. The client needs constant supervision by a hospital employee until a secure room is available. The client should never be left alone without hospital supervision. (Option 1) A verbal contract is a viable option but might not be accomplished appropriately in the triage area. Also, its efficacy is questionable. Emergency department triage should be accomplished in 3-5 minutes. In addition, the