Question 1

A client has been diagnosed with post-traumatic stress disorder following a rape by an unknown assailant. The nurse should give priority to?

Accepted Answer

Answer reason: Following trauma, the priority is to ensure safety and to offer a supportive, trusting environment to reduce anxiety and facilitate stabilization. Exploring details or focusing on anger control can occur later; sedatives address a symptom but not the immediate psychosocial need.

Question 2

A client on the psychiatric unit is in an uncontrolled rage and threatening other clients and staff. What is the most appropriate action for the nurse to take?

Accepted Answer

Answer reason: The client poses an immediate safety threat; priority is to protect clients and staff by obtaining assistance and preparing to administer PRN medication if ordered. The other options are nontherapeutic, escalate risk, or leave the situation unsafe.

Question 3

The goals of crisis intervention include all of the following, Except-?

Accepted Answer

Answer reason: Crisis intervention goals are to ensure safety, reduce anxiety, address the precipitating problem, and restore pre‑crisis functioning. Increasing anxiety is not a goal.

Question 4

Which one of the following situations represents a maturational crisis for the family?

Accepted Answer

Answer reason: Maturational crises stem from normal developmental transitions requiring role changes; starting nursery school is a predictable life-cycle event. The other options are situational or accidental stressors.

Question 5

A client treated for depression tells the nurse at the mental health clinic that he recently purchased a handgun because he is thinking about suicide. The FIRST nursing action should be to?

Accepted Answer

Answer reason: Client has suicidal ideation with a plan and means (purchased handgun), indicating imminent danger. The nurse must act for immediate safety by notifying the physician/mental health team for possible emergency hospitalization. Confidentiality can be breached for safety; contacting family or suggesting care is not the first action.

Question 6

A middle-aged woman is brought to the emergency room after being raped in her home. The client asks the nurse to call her husband to come to the emergency room. The nurse knows that the most common reaction of significant others to a rape victim is reflected in which of the following statements?

Accepted Answer

Answer reason: Significant others commonly experience acute emotional distress after a rape and often require support and guidance themselves; this is best reflected by option 4.

Question 7

A depressed client who has recently been acting suicidal is now more social and energetic than usual. Smilingly he tells the nurse "I've made some decisions about my life." What should be the nurse's INITIAL response?

Accepted Answer

Answer reason: Sudden improvement in mood and energy in a depressed client can signal imminent suicide risk. The priority initial action is to directly assess for suicidal ideation and intent by asking about thoughts of killing oneself.

Question 8

A client with major depressive disorder reports suicidal thoughts. Which action should the nurse take first?

Accepted Answer

Answer reason: Reports of suicidal thoughts require immediate suicide risk assessment and safety measures to prevent self-harm. Encouraging positivity, ignoring, or allowing privacy is unsafe and nontherapeutic.

Question 9

When teaching suicide prevention to the parents of a 15 year-old who recently attempted suicide, the nurse describes the following behavioral cue?

Accepted Answer

Answer reason: Giving away prized possessions is a classic warning sign of suicidal intent; the other options are nonspecific reactions or precipitating events rather than a key behavioral cue.

Question 10

Parents of a 4 year-old boy have just been informed that their son has a congenital neurologic demyelinating disorder that is terminal. The nurse evaluates their reaction as which phase of the crisis process?

Accepted Answer

Answer reason: They were just informed of terminal news; the immediate response to a precipitating event is the impact phase, marked by shock, intense stress, and disorganization. Pre-crisis precedes the event; crisis phase reflects failed coping over time; resolution follows adaptation.

Question 11

Which of the following is not a psychiatric emergency?

Accepted Answer

Answer reason: Suicidal behavior, violent behavior, and acute crisis states require immediate intervention; dementia is a chronic condition and not typically a psychiatric emergency.

Question 12

A client with schizophrenia reports hearing voices commanding self-harm. The client appears anxious and fearful. What is the nurse's BEST initial response?

Accepted Answer

Answer reason: Command hallucinations to self-harm indicate an immediate safety risk, so the nurse’s first priority is to assess suicidality directly, including intent and plan. Asking about a specific plan helps determine the level of imminent danger and guides urgent interventions (e.g., continuous observation, removal of hazards, notifying the provider). Reassuring that voices are not real can invalidate the client’s experience, distraction delays safety assessment, and increasing stimulation can worsen anxiety or psychosis.

Question 13

A client with schizophrenia reports hearing voices commanding self-harm. The client appears anxious and restless. Which nursing action is the BEST initial response?

Accepted Answer

Answer reason: Command hallucinations to self-harm indicate an immediate safety risk, so the priority is to assess suicidal intent, plan, and means. Asking directly about a plan is an evidence-based crisis intervention and does not increase risk; it guides urgency of supervision and protective actions. Reassurance or distraction may invalidate the client’s experience and delays essential risk assessment, while increasing stimulation can worsen anxiety and psychosis.

Question 14

A client is admitted to the mental health unit and reports taking extra anxiety medication because, "I'm so stressed out. I just want to go to sleep." The RN should plan one-on-one observation of the client based on which statement?

Accepted Answer

Answer reason: The statement "Nothing matters anymore" reflects hopelessness and possible suicidal ideation, which requires the highest level of immediate safety intervention, including one-on-one observation. Combined with recent overuse of anxiolytic medication and a desire to "go to sleep," there is increased concern for self-harm or overdose risk. The other statements indicate distress, fatigue, or lack of insight but are less specific indicators of imminent self-harm compared with pervasive hopelessness.

Question 15

The occupational health nurse is working with a female employee who was just notified that her child was involved in an MVA and taken to the hospital. The employee states, "I can't believe this happened. What should I do?" Which response is best for the RN to provide in this crisis?

Accepted Answer

Answer reason: This is an acute crisis where the client is overwhelmed and needs immediate, concrete assistance rather than exploratory questions. The most therapeutic and safe nursing response is to take action that supports problem-solving and restores a sense of control. Arranging transportation to the hospital directly addresses the immediate need and helps the employee mobilize coping resources. The other options focus on interpretation or information gathering and do not provide timely support in the crisis moment.

Question 16

A client expresses suicidal thoughts during therapy. What should the nurse do first?

Accepted Answer

Answer reason: Expression of suicidal thoughts requires immediate escalation to ensure patient safety. Collaboration with the mental health team allows rapid implementation of suicide precautions and treatment planning.

Question 17

A nurse is caring for a client with major depressive disorder who suddenly becomes cheerful and gives away belongings. What should the nurse do first?

Accepted Answer

Answer reason: A sudden uplift in mood with giving away possessions in a client with major depressive disorder can signal imminent suicide risk, as the client may have resolved to act and now has energy to carry out a plan. The nurse’s immediate priority is to assess for suicidal ideation, plan, intent, and means to determine the level of risk and the need for urgent safety measures. Provider notification and environmental safety interventions follow based on the assessment findings, but the first step is direct suicide assessment to guide rapid protective action.

Question 18

Postpartum Depression vs. Postpartum Psychosis A 3-week postpartum client reports severe insomnia, delusions, and thoughts of harming her baby. What is the priority nursing action?

Accepted Answer

Answer reason: Severe insomnia with delusions and thoughts of harming the infant is most consistent with postpartum psychosis, which is a psychiatric emergency. The priority is immediate safety of both the client and the baby, requiring urgent evaluation and inpatient psychiatric hospitalization. Outpatient counseling, sleep hygiene advice, or relying on family support are insufficient because the client has impaired reality testing and potential for imminent harm.

Question 19

A client with severe anxiety is pacing & hyperventilating. What is the priority nursing action?

Accepted Answer

Answer reason: With severe anxiety and hyperventilation, the immediate priority is to reduce physiologic arousal and restore effective breathing while providing a low-stimulation environment. Moving the client to a quiet area and coaching slow, deep breathing helps correct hyperventilation and can rapidly decrease panic symptoms. Exploring triggers or teaching new coping skills (guided imagery) is more appropriate once the client is calmer and able to process information. Telling the client to “stop acting” is nontherapeutic and can escalate anxiety.

Question 20

The nurse is assessing a client in an outpatient healthcare clinic. The client states, “I hate myself. I wish it would all just end!” Which response by the nurse is appropriate?

Accepted Answer

Answer reason: The client’s statement suggests possible suicidal ideation, and the priority nursing action is to assess safety with a direct, empathetic question about self-harm. Asking directly does not increase suicide risk and helps determine immediacy and need for protective interventions. The other responses either minimize/discount feelings, delay suicide-risk assessment, or jump to disposition without first establishing the level of risk.

Question 21

A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client?

Accepted Answer

Answer reason: The client is exhibiting acute anxiety/panic symptoms after a traumatic event (agitation, trembling, hyperventilation), so the immediate priority is safety and anxiety reduction. Remaining with the client provides reassurance, conveys security, and allows the nurse to observe for escalation and intervene promptly (e.g., grounding, coaching slow breathing). Teaching relaxation techniques and processing the assault are not effective during the peak of panic when the client cannot learn or meaningfully discuss details. Placing the client alone may increase fear, worsen panic, and reduces monitoring during an unstable period.

Question 22

A patient with anxiety is hyperventilating. What is the first nursing action?

Accepted Answer

Answer reason: In acute anxiety with hyperventilation, the priority is immediate nonpharmacologic intervention to reduce respiratory alkalosis symptoms (e.g., dizziness, paresthesias) and regain control. Coaching slow, controlled breathing and providing calm reassurance is a first-line nursing action and can rapidly stabilize the patient. Calling the provider or administering a benzodiazepine may be appropriate if symptoms persist or are severe, but they are not the first step when the patient can be guided to self-regulate. Offering water does not address the primary problem of hyperventilation.

Question 23

A client says, "I feel like I can’t go on anymore." What is the most appropriate response?

Accepted Answer

Answer reason: The statement suggests possible suicidal ideation, so the nurse’s priority is to assess safety directly and immediately. Asking about self-harm is therapeutic, nonjudgmental, and allows determination of risk and need for urgent intervention. The other options provide false reassurance, minimize feelings, or deflect to others, which can shut down communication and delay safety assessment.

Question 24

A client experiencing a panic attack says, “I can’t breathe, I think I’m dying.” What is the priority nursing action?

Accepted Answer

Answer reason: During an acute panic attack, the immediate priority is to ensure safety and reduce escalating anxiety; staying with the client and remaining calm provides reassurance and prevents the client from feeling abandoned. A calm, supportive presence helps decrease panic intensity and allows for further assessment of breathing and overall status. Teaching techniques or exploring feelings is better once the client is more stable, and medication is not the first nursing action unless prescribed and other immediate measures are insufficient.

Question 25

The nurse is caring for a client newly admitted to the mental health unit with bulimia nervosa. Which client statement requires immediate follow-up?

Accepted Answer

Answer reason:  “I hate my life and wish it was over.” This statement indicates possible suicidal ideation, which is an immediate safety concern requiring prompt assessment of intent, plan, means, and level of risk. In a newly admitted patient with an eating disorder and comorbid depression/anxiety risk, prioritizing suicide precautions and rapid provider notification is essential. The other statements may reflect complications of bulimia (oral trauma, obsession with weighing, dizziness from dehydration/electrolyte imbalance), but they do not supersede imminent self-harm risk.

Question 26

The nurse is caring for a client with panic disorder who is experiencing tachypnea, dizziness, and diaphoresis. Which of the following actions should the nurse take?

Accepted Answer

Answer reason:  Stay with the client and communicate calmly and clearly. During an acute panic attack, the priority nursing action is to provide immediate safety and decrease anxiety by remaining with the client and using a calm, simple, reassuring approach. This helps reduce fear, provides grounding, and supports controlled breathing without overwhelming the client with complex instructions. SSRIs like escitalopram are for long-term management and will not relieve acute symptoms, and techniques like guided imagery are better for prevention/when the client is calmer. Instructing a Valsalva maneuver (bear down) is not a standard intervention for panic symptoms and does not address the acute anxiety state.

Question 27

True or False The priority intervention for a patient experiencing a panic attack is deep breathing exercises?

Accepted Answer

Answer reason: In a panic attack, the immediate priority is to ensure safety and reduce overwhelming anxiety by staying with the patient, using a calm, firm approach, and providing simple, brief directions in a low-stimulus environment. Deep breathing can be introduced once the patient is able to focus and follow instructions; early on, it may be ineffective or even worsen hyperventilation if coached poorly. Crisis-focused interventions and reassurance help regain a sense of control before teaching coping techniques. After stabilization, relaxation and breathing exercises are appropriate for ongoing management and prevention.

Question 28

A nurse is assessing a patient who reports feeling hopeless. Which question best evaluates suicidal ideation?

Accepted Answer

Answer reason: Direct, specific questioning is the most appropriate and reliable way to assess for suicidal ideation when a patient expresses hopelessness. Asking about self-harm thoughts helps identify immediate risk and guides the need for safety precautions and urgent mental health interventions. Indirect questions about sleep, appetite, or hobbies may indicate depression severity but do not adequately assess imminent self-harm risk. Clear assessment supports timely escalation and protective measures to prevent harm.

Question 29

The occupational health nurse is working with a female employee who was just notified that her child was involved in an MVA and taken to the hospital. The employee states, "I can't believe this. What should I do?" Which response is best for the RN to provide in this crisis?

Accepted Answer

Answer reason: In an acute crisis, the priority is immediate, practical support to reduce anxiety and promote safety and effective coping. A directive action helps the client regain a sense of control and addresses urgent needs (getting to the child’s location). The other responses are open-ended but can delay action and may be inappropriate when the person is overwhelmed and needs clear, supportive guidance.

Question 30

What is the nurse's best response?

Accepted Answer

Answer reason: " Directly assessing for suicidal ideation is a priority safety action when a client may be depressed or giving cues of self-harm. Asking clearly and nonjudgmentally helps determine immediate risk and guides next steps such as initiating precautions and notifying the provider. The other responses minimize feelings, give generic advice, or delay assessment, which can miss imminent danger.

Question 31

A patient with major depressive disorder says to the nurse, "I feel like a burden to everyone. I don’t want to be here anymore." What is the nurse’s best response?

Accepted Answer

Answer reason:  When a patient expresses passive suicidal ideation (“don’t want to be here anymore”), the priority is immediate suicide risk assessment using direct, clear questioning to determine presence of self-harm thoughts and need for urgent safety measures. This response is therapeutic and nonjudgmental, and it opens the door to further assessment of plan, intent, means, and protective factors. Options A and D minimize the patient’s feelings and can shut down disclosure, increasing risk. Option B may be appropriate later, but it delays the priority action of assessing imminent danger.

Question 32

A client is currently experiencing a panic attack. Which is the most therapeutic response by the nurse?

Accepted Answer

Answer reason: "You are safe. Take a deep breath." During a panic attack, the priority is immediate anxiety reduction and physiologic stabilization using simple, direct, grounding communication. This response provides reassurance of safety and offers a concrete breathing action that can reduce hyperventilation, sympathetic arousal, and escalating fear. Brief directions are easier to process when the client’s ability to concentrate is impaired by panic. In contrast, telling the client to “just relax” is vague and can feel dismissive, potentially worsening anxiety.

Question 33

A depressed client who has recently been acting suicidal is now more social and energetic than usual. Smilingly he tells the nurse "I've made some decisions about my life." What should be the nurse's initial response?

Accepted Answer

Answer reason: " A sudden improvement in mood/energy in a previously suicidal depressed client can indicate increased capacity and resolve to act on a suicide plan, making immediate risk assessment the priority. The safest initial nursing response is direct, specific questioning about suicidal thoughts to determine current intent and guide urgent precautions (e.g., observation level, removal of means, emergency evaluation). This approach is therapeutic and does not “plant” the idea; instead, it opens communication and allows timely intervention. The other options either minimize the warning sign, provide premature reassurance, or defer assessment to another provider, delaying potentially life-saving action.

Question 34

When teaching suicide prevention to the parents of a 15 year-old who recently attempted suicide, the nurse describes the following behavioral cue?

Accepted Answer

Answer reason: ” This behavior reflects intent and planning by disposing of meaningful belongings and saying goodbye in a concrete way, which is more specific than nonspecific mood or interpersonal conflict. Angry outbursts and fear of being alone can occur in many adolescent mental health conditions and do not uniquely signal imminent suicidal action. A breakup is a risk factor/stressor, but it is not itself a behavioral cue that indicates active preparation.

Question 35

A client experiences intense anxiety after the home was destroyed by a fire. The client escaped from the fire with only minor injuries. The nurse knows that the most important initial intervention would be to?

Accepted Answer

Answer reason: After a house fire, urgent concerns often include shelter, finances, access to medications, family support, and community disaster services; addressing these reduces anxiety and restores a sense of control. Teaching relaxation strategies can help later, but it does not resolve the primary situational stressors driving the acute anxiety. Exploring grief is appropriate once immediate coping supports are in place and the client is more stabilized.

Question 36

You are working in a community that has just experienced a hurricane. You are trying to find housing and counseling for those who need it. Which type of level of preventions are you representing?

Accepted Answer

Answer reason: After a hurricane, securing housing addresses post-disaster displacement and safety needs, and counseling targets psychological recovery and coping. These actions are rehabilitative and supportive services intended to prevent further deterioration and long-term complications. In contrast, primary prevention would involve disaster preparedness measures before the hurricane, and secondary prevention would emphasize early detection/screening of problems shortly after exposure.

Question 37

A nurse is caring for a client who is experiencing an anxiety attack. Which of the following actions should the nurse do first?

Accepted Answer

Answer reason: Removing the client from a noisy, crowded setting is a rapid, low-risk first intervention that can quickly lower perceived threat and facilitate further coaching. After the environment is controlled, the nurse can more effectively guide slow, deep breathing to reduce hyperventilation and physiologic symptoms. Sedatives are not first-line because they require an order and carry adverse-effect risks, and cognitive behavioral therapy is a longer-term treatment rather than an acute attack intervention.

Question 38

A nurse is working in a psychiatric unit and receives reports on four clients. Which client should the nurse assess first?

Accepted Answer

Answer reason: " This statement signals possible suicidal ideation and hopelessness, which is the highest-priority psychiatric risk because it can indicate imminent self-harm. The nurse should immediately assess for suicide risk (thoughts, plan, means, intent) and institute safety precautions as indicated. The OCD ritual behavior and missed antipsychotic dose are important but are not as immediately life-threatening without signs of acute agitation, psychosis with command hallucinations, or medical instability. The borderline client’s threat to leave requires prompt limit-setting and safety monitoring, but it is secondary to evaluating potential suicide risk.

Question 39

Which is an example of tertiary prevention in disaster planning?

Accepted Answer

Answer reason: Providing psychological support and education about expected stress responses helps survivors cope, decreases risk of long-term sequelae (e.g., PTSD), and supports rehabilitation. In contrast, immunizations and drills are primarily pre-event risk reduction activities, and biohazard precautions are aimed at preventing exposure during response (more aligned with primary prevention). Therefore, post-event counseling for stress reactions best fits tertiary prevention.

Question 40

A 24-year-old client undergoes a traumatic belowthe-knee amputation. The nurse assesses the client for risk of suicide. Which is a risk factor for suicide?

Accepted Answer

Answer reason: Hopelessness is a high-yield, proximal predictor of suicidal ideation and attempts because it reflects perceived lack of future, control, and relief from suffering. After a traumatic amputation, intense grief, loss of function, and sudden change in identity can amplify hopeless cognition, raising immediate suicide risk. By contrast, female sex is more associated with higher attempt rates but not the strongest universal risk indicator compared with hopelessness, and “living with family” is typically protective through social support and monitoring. While certain age groups confer increased risk, “age” alone without specifying a high-risk bracket is less specific than the presence of hopelessness.

Question 41

A client is scheduled to retire in the next month. He phones his nurse therapist and says he can't cope; his whole world is falling apart. The therapist recognizes this reaction as which of the following?

Accepted Answer

Answer reason: The client’s statement that he “can’t cope” and that his “whole world is falling apart” reflects difficulty adjusting to this predictable developmental milestone rather than an unexpected event. A situational crisis is typically precipitated by sudden, extraordinary stressors (eg, job loss, accident, death) rather than a planned transition. Panic reaction describes an acute anxiety episode but does not capture the underlying developmental trigger and adjustment focus central to this scenario.

Question 42

The nurse is assessing the client who has begun therapy with duloxetine. Which assessment parameter should be the nurse’s priority?

Accepted Answer

Answer reason: In priority setting, immediate life-threatening risk outweighs monitoring for efficacy or non-acute adverse effects. New or worsening agitation/anxiety can be important, but it is primarily concerning because it may signal escalating suicidality, which must be assessed directly. LFT monitoring matters due to potential hepatotoxicity, yet it is generally not as time-critical as assessing for self-harm risk during the initial assessment.

Question 43

Which outcome is most appropriate for a client with a diagnosis of depression and attempted suicide?

Accepted Answer

Answer reason: Outcomes for a client after a suicide attempt should be specific, measurable, and directly tied to immediate safety. A key indicator of reduced acute risk is the client’s stated lack of current suicidal thoughts along with no plan or intent, which supports ongoing risk assessment and safety planning. “Never feel suicidal again” is unrealistic and not measurable, and it ignores the relapsing nature of depression and suicidal crises. Housing placement and a fixed prolonged hospitalization are not universal or appropriate outcome targets and do not directly measure the urgent suicide-risk reduction needed.

Question 44

The client is placed in seclusion for exhibiting violent behavior. Which should be the nurse’s primary goal of this seclusion?

Accepted Answer

Answer reason: The nurse’s top priority is preventing injury to the client, staff, and other clients while maintaining continuous monitoring and timely reassessment. Helping the client regain self-control is an important therapeutic outcome, but it is secondary to immediate safety during an episode of violence. Seclusion is not intended as punishment or to restore “unit control,” and using it as a consequence violates legal/ethical standards for least-restrictive care.

Question 45

The nurse is interviewing the client at a mental health clinic who recently attempted suicide and continues to report active suicidal ideation. Which care setting is most appropriate for this client?

Accepted Answer

Answer reason: An inpatient psychiatric unit provides 24/7 monitoring, structured milieu therapy, rapid psychiatric evaluation, and timely initiation/adjustment of medications while maintaining safety. Outpatient care lacks constant supervision and is inappropriate when the client cannot be reliably kept safe. A general acute care hospital unit is not the best setting unless there are unstable medical injuries/toxicity requiring medical management, and a detoxification center is only indicated when substance withdrawal is the primary problem needing detox services.

Question 46

An alcoholic client tells the nurse, “I feel so depressed about what I’ve done to my family that I feel like giving up.” It is most important for the nurse to assess the client for which of the following?

Accepted Answer

Answer reason: The nurse’s priority is to determine whether there is suicidal ideation with intent, a specific plan, and access to means so urgent protective interventions can be initiated. This assessment directly addresses imminent risk and guides need for constant observation, removal of hazards, and rapid psychiatric evaluation. While family support and a sponsor are important for recovery, they are secondary to ruling out immediate self-harm risk. Exploring ambivalence is therapeutic, but it does not supersede establishing safety when suicide risk is possible.

Question 47

The client is experiencing withdrawal symptoms leading to sleep deprivation. The nurse should recognize that the client is at greatest risk for violent behavior due to which assessment finding?

Accepted Answer

Answer reason: Withdrawal-related pain increases irritability, lowers frustration tolerance, and makes impulsive, reactive behavior more likely during periods of decreased coping capacity. This finding represents an immediate, modifiable trigger that can be targeted with assessment and symptom management to reduce escalation risk. In contrast, guilt/shame and generalized poor coping are important psychosocial concerns but are less predictive of imminent violence than acute, severe physical discomfort in an aroused, sleep-deprived client.

Question 48

The newly admitted client is expressing anger with increasing intensity. Which therapeutic site should the nurse recommend to the client for gaining control over the increasing anger?

Accepted Answer

Answer reason: Locating the client near the nursing station allows rapid intervention if agitation progresses, without placing the client in a public area that can increase arousal. A private room down the hall reduces visibility and increases risk if the client becomes violent or self-harming. Dayroom or smoking areas add noise, crowds, and potential triggers, making loss of control more likely.

Question 49

The nurse in the ED is admitting an agitated young adult who tried to jump from a bridge after taking a hallucinogenic drug at a party. What should be the nurse’s initial action?

Accepted Answer

Answer reason: The priority in an acute behavioral emergency with recent suicide attempt and intoxication is immediate safety and continuous observation. Remaining with the client provides rapid intervention to prevent impulsive self-injury while de-escalation measures and additional help are mobilized. Medication to “reverse” hallucinogens is not a reliable first-line approach because there is no specific antidote for most hallucinogens, and sedation is considered only after safety is ensured. Arranging inpatient care or calling security may become necessary, but they do not replace the nurse’s immediate duty to maintain one-to-one safety at the bedside.

Question 50

The nurse is caring for four clients in the ED. Which cheat has the greatest potential for demonstrating violent behavior toward the staff?

Accepted Answer

Answer reason: Intoxicated clients may misinterpret interventions as threats, have poor impulse control, and can escalate quickly during painful procedures or when limits are set. In contrast, severe pain or a history of a fight can raise stress but does not inherently create the same level of unpredictable disinhibition as intoxication. A diagnosis of schizophrenia alone is not the strongest predictor of violence; risk is more closely tied to acute agitation, command hallucinations, intoxication, or recent violent behavior.

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A client has been diagnosed with post-traumatic stress disorder following a rape by an unknown assailant. The nurse should give priority to?

A client on the psychiatric unit is in an uncontrolled rage and threatening other clients and staff. What is the most appropriate action for the nurse to take?

The goals of crisis intervention include all of the following, Except-?

Which one of the following situations represents a maturational crisis for the family?

A client treated for depression tells the nurse at the mental health clinic that he recently purchased a handgun because he is thinking about suicide. The FIRST nursing action should be to?

A middle-aged woman is brought to the emergency room after being raped in her home. The client asks the nurse to call her husband to come to the emergency room. The nurse knows that the most common reaction of significant others to a rape victim is reflected in which of the following statements?

A depressed client who has recently been acting suicidal is now more social and energetic than usual. Smilingly he tells the nurse "I've made some decisions about my life." What should be the nurse's INITIAL response?

A client with major depressive disorder reports suicidal thoughts. Which action should the nurse take first?

When teaching suicide prevention to the parents of a 15 year-old who recently attempted suicide, the nurse describes the following behavioral cue?

Parents of a 4 year-old boy have just been informed that their son has a congenital neurologic demyelinating disorder that is terminal. The nurse evaluates their reaction as which phase of the crisis process?

Which of the following is not a psychiatric emergency?

A client with schizophrenia reports hearing voices commanding self-harm. The client appears anxious and fearful. What is the nurse's BEST initial response?

A client with schizophrenia reports hearing voices commanding self-harm. The client appears anxious and restless. Which nursing action is the BEST initial response?

A client is admitted to the mental health unit and reports taking extra anxiety medication because, "I'm so stressed out. I just want to go to sleep." The RN should plan one-on-one observation of the client based on which statement?

The occupational health nurse is working with a female employee who was just notified that her child was involved in an MVA and taken to the hospital. The employee states, "I can't believe this happened. What should I do?" Which response is best for the RN to provide in this crisis?

A client expresses suicidal thoughts during therapy. What should the nurse do first?

A nurse is caring for a client with major depressive disorder who suddenly becomes cheerful and gives away belongings. What should the nurse do first?

Postpartum Depression vs. Postpartum Psychosis A 3-week postpartum client reports severe insomnia, delusions, and thoughts of harming her baby. What is the priority nursing action?

A client with severe anxiety is pacing & hyperventilating. What is the priority nursing action?

The nurse is assessing a client in an outpatient healthcare clinic. The client states, “I hate myself. I wish it would all just end!” Which response by the nurse is appropriate?

A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client?

A patient with anxiety is hyperventilating. What is the first nursing action?

A client says, "I feel like I can’t go on anymore." What is the most appropriate response?

A client experiencing a panic attack says, “I can’t breathe, I think I’m dying.” What is the priority nursing action?

The nurse is caring for a client newly admitted to the mental health unit with bulimia nervosa. Which client statement requires immediate follow-up?

The nurse is caring for a client with panic disorder who is experiencing tachypnea, dizziness, and diaphoresis. Which of the following actions should the nurse take?

True or False The priority intervention for a patient experiencing a panic attack is deep breathing exercises?

A nurse is assessing a patient who reports feeling hopeless. Which question best evaluates suicidal ideation?

The occupational health nurse is working with a female employee who was just notified that her child was involved in an MVA and taken to the hospital. The employee states, "I can't believe this. What should I do?" Which response is best for the RN to provide in this crisis?

What is the nurse's best response?

A patient with major depressive disorder says to the nurse, "I feel like a burden to everyone. I don’t want to be here anymore." What is the nurse’s best response?

A client is currently experiencing a panic attack. Which is the most therapeutic response by the nurse?

A depressed client who has recently been acting suicidal is now more social and energetic than usual. Smilingly he tells the nurse "I've made some decisions about my life." What should be the nurse's initial response?

When teaching suicide prevention to the parents of a 15 year-old who recently attempted suicide, the nurse describes the following behavioral cue?

A client experiences intense anxiety after the home was destroyed by a fire. The client escaped from the fire with only minor injuries. The nurse knows that the most important initial intervention would be to?

You are working in a community that has just experienced a hurricane. You are trying to find housing and counseling for those who need it. Which type of level of preventions are you representing?

A nurse is caring for a client who is experiencing an anxiety attack. Which of the following actions should the nurse do first?

A nurse is working in a psychiatric unit and receives reports on four clients. Which client should the nurse assess first?

Which is an example of tertiary prevention in disaster planning?

A 24-year-old client undergoes a traumatic belowthe-knee amputation. The nurse assesses the client for risk of suicide. Which is a risk factor for suicide?

A client is scheduled to retire in the next month. He phones his nurse therapist and says he can't cope; his whole world is falling apart. The therapist recognizes this reaction as which of the following?

The nurse is assessing the client who has begun therapy with duloxetine. Which assessment parameter should be the nurse’s priority?

Which outcome is most appropriate for a client with a diagnosis of depression and attempted suicide?

The client is placed in seclusion for exhibiting violent behavior. Which should be the nurse’s primary goal of this seclusion?

The nurse is interviewing the client at a mental health clinic who recently attempted suicide and continues to report active suicidal ideation. Which care setting is most appropriate for this client?

An alcoholic client tells the nurse, “I feel so depressed about what I’ve done to my family that I feel like giving up.” It is most important for the nurse to assess the client for which of the following?

The client is experiencing withdrawal symptoms leading to sleep deprivation. The nurse should recognize that the client is at greatest risk for violent behavior due to which assessment finding?

The newly admitted client is expressing anger with increasing intensity. Which therapeutic site should the nurse recommend to the client for gaining control over the increasing anger?

The nurse in the ED is admitting an agitated young adult who tried to jump from a bridge after taking a hallucinogenic drug at a party. What should be the nurse’s initial action?

The nurse is caring for four clients in the ED. Which cheat has the greatest potential for demonstrating violent behavior toward the staff?

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