Question

A client, assessed in the emergency department (ED), has a strong odor of alcohol on the breath. The client denies thoughts of harm to self or others, and the healthcare provider (HCP) discharges the client. As the client begins to leave, the nurse overhears the client mumble, "Now I'm going to shoot myself. "Which intervention should the nurse implement?

Answer 1

Correct Answers:

Stop the client from leaving the ED.

Rationale :

🚨A direct suicidal statement such as threatening to shoot oneself represents an immediate risk for self-harm that requires urgent intervention.

🛡️The nurse's highest priority is maintaining client safety, so the client should not be permitted to leave until further assessment occurs.

🏥The client requires an immediate suicide-risk evaluation by the appropriate healthcare team because the threat involves a potentially lethal method.

⚠️Alcohol use can further impair judgment and impulse control, increasing concern that the stated suicidal intent might be acted upon.

📌Core Message

A client expressing an immediate suicidal threat must be kept in a safe clinical environment until an urgent suicide-risk assessment is completed.

Answer 2

Correct Answers:

"Did someone cause these injuries to happen?"

Rationale :

🩹The combination of unexplained fractures, facial bruising, avoidance of eye contact, and evasive responses raises concern for interpersonal violence or abuse.

🗣️A clear, direct question about whether another person caused the injuries allows the nurse to perform appropriate violence screening.

🤝Direct questioning should remain nonjudgmental and objective so the client has an opportunity to disclose possible abuse safely.

🛡️Identifying possible intentional injury is essential because disclosure can lead to appropriate safety planning and intervention.

📌Core Message

Suspicious or inconsistent injury explanations require direct, nonjudgmental assessment for possible interpersonal violence so appropriate safety measures can be initiated.

Answer 3

Correct Answers:

Performs activities of daily living for 3 sequential days.

Rationale :

🧠Dementia is generally a progressive disorder, so care focuses heavily on maintaining the client's highest possible level of functional independence.

🧼Successful completion of activities of daily living is an observable, measurable outcome that reflects preserved functional ability.

📅Performance over three sequential days provides a specific time frame, making the outcome appropriate for evaluating short-term progress.

🎯Realistic dementia outcomes emphasize maintaining existing abilities and independence rather than expecting restoration of permanently lost cognitive functions.

📌Core Message

Effective short-term dementia care emphasizes maintaining functional independence through measurable performance of activities of daily living despite progressive cognitive decline.

Answer 4

Correct Answers:

Allow the client to identify the way he interacts.

Rationale :

👉By reproducing the client's posture, eye contact, and speech pattern, the nurse uses a form of mirroring or behavioral feedback.

👀This technique allows the client to observe previously unrecognized aspects of their own communication behavior.

💁‍♂️Increasing awareness of nonverbal communication can help the client identify how others might perceive their interactions.

🌱Once the client recognizes the behavior, therapeutic work can focus on developing more effective interpersonal skills.

📌Core Message

Therapeutic mirroring helps clients recognize their own communication patterns, increasing self-awareness and supporting improvement in interpersonal behavior.

Answer 5

Correct Answers:

Initiate short, frequent contacts with the client.

Rationale :

🤝Clients with delusional disorder, particularly persecutory beliefs, often have significant distrust of others.

⏱️Brief, frequent interactions allow the nurse to establish consistency and reliability without overwhelming the client.

🌱Repeated neutral interactions gradually support development of a therapeutic relationship and increase the client's sense of safety.

🛡️The nurse should avoid directly challenging the delusion, because confrontation can intensify defensiveness and reduce trust.

📌Core Message

Clients experiencing paranoid delusions benefit from short, consistent, nonthreatening interactions that gradually establish trust and therapeutic rapport.

Answer 6

Correct Answers:

Displacement.

Rationale :

🎯Displacement occurs when feelings directed toward one person or situation are redirected toward a safer or more accessible target.

😠The client's frustration originates from the perceived rejection or absence of family and friends.

💥Instead of expressing anger toward those individuals, the client directs the anger and aggressive behavior toward the nurse.

🧠This transfer of emotion from the original source to another person is characteristic of the displacement defense mechanism.

📌Core Message

Displacement redirects uncomfortable emotions from their original source toward a different, usually safer target.

Answer 7

Correct Answers:

Review liver function results.

Rationale :

💊Carbamazepine is metabolized extensively by the liver and can cause clinically significant hepatotoxicity.

🧪Reviewing baseline liver function tests helps identify existing hepatic impairment before medication administration.

⚠️During therapy, abnormal hepatic laboratory values may require further evaluation because continued exposure could worsen liver injury.

🩸Carbamazepine also requires monitoring for serious hematologic toxicity, although liver function is the relevant assessment among the listed choices.

📌Core Message

Safe carbamazepine therapy requires evaluation of hepatic function because the medication is extensively metabolized by the liver and may cause hepatotoxicity.

Answer 8

Correct Answers:

Recommend assignment to the receptionist's office.

Rationale :

🍽️A client recovering from anorexia nervosa should avoid situations that may intensify excessive focus on food, eating, or weight during recovery.

☎️Working in a receptionist role provides productive work experience without unnecessary exposure to a food-centered environment.

🧠Reducing environmental triggers can support healthier thought patterns and eating behaviors during continued recovery.

🌱A non-food-related assignment promotes participation in normal activities while protecting progress toward nutritional and psychological stability.

📌Core Message

During recovery from anorexia nervosa, appropriate activities should promote normal functioning while minimizing environments that may reinforce food, weight, or exercise preoccupation.

Answer 9

Correct Answers:

Use a calm voice to remind of set limits.

Rationale :

🎶The client's loud singing and dancing demonstrate manic hyperactivity that is interfering with the therapeutic environment.

🗣️Clear, calm, consistent limit setting is a priority intervention when manic behavior begins disrupting other clients.

🧱Previously established behavioral limits provide structure because clients experiencing mania often have impaired judgment and difficulty controlling impulsive behavior.

🌤️A calm approach decreases unnecessary stimulation while communicating the expected behavioral boundaries without escalating confrontation.

📌Core Message

Disruptive manic behavior should initially be managed with calm, clear, consistent limit setting that maintains safety while using the least restrictive intervention.

Answer 10

Correct Answers:

"The other nurses and I are here to help you get better."

Rationale :

🧩Clients with borderline personality disorder commonly use splitting, viewing some staff members as exceptionally good while portraying others as uncaring or bad.

🤝The nurse should promote team consistency by emphasizing that all staff members share responsibility for the client's treatment.

🛡️A unified approach prevents the client from manipulating relationships or creating staff division within the therapeutic environment.

🌿Maintaining consistent professional boundaries also supports a stable therapeutic relationship without validating the client's polarized perceptions.

📌Core Message

Effective management of splitting behavior requires consistent team communication, unified responses, and firm professional boundaries that prevent staff division.

3 :
Which short-term outcome should the nurse include in the initial treatment plan for a client with dementia?

5 :
The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?

6 :
A client reports to the nurse about feeling upset because no family or friends have visited in two days. The client then begins to shout and toss small objects toward the nurse. Which defense mechanism should the nurse recognize the client is displaying?

7 :
A client with bipolar disorder receives a new prescription for carbamazepine. Which action should the nurse perform before administering the medication?

8 :
After receiving treatment for anorexia nervosa, a student asks the school nurse for permission to work in the school cafeteria as part of the school's work study program. Which action should the nurse take?

9 :
A client with bipolar 1 disorder starts to sing loudly and dance around the dining area disturbing other clients. Which intervention should the nurse implement first?

10 :
A client with borderline personality disorder tells the nurse, "You are the best nurse on the unit! The other nurses don't care about me the way you do." Which response should the nurse provide to this client?

3 : Which short-term outcome should the nurse include in the initial treatment plan for a client with dementia?

5 : The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?

6 : A client reports to the nurse about feeling upset because no family or friends have visited in two days. The client then begins to shout and toss small objects toward the nurse. Which defense mechanism should the nurse recognize the client is displaying?

7 : A client with bipolar disorder receives a new prescription for carbamazepine. Which action should the nurse perform before administering the medication?

8 : After receiving treatment for anorexia nervosa, a student asks the school nurse for permission to work in the school cafeteria as part of the school's work study program. Which action should the nurse take?

9 : A client with bipolar 1 disorder starts to sing loudly and dance around the dining area disturbing other clients. Which intervention should the nurse implement first?

10 : A client with borderline personality disorder tells the nurse, "You are the best nurse on the unit! The other nurses don't care about me the way you do." Which response should the nurse provide to this client?

3 :
Which short-term outcome should the nurse include in the initial treatment plan for a client with dementia?

5 :
The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?

6 :
A client reports to the nurse about feeling upset because no family or friends have visited in two days. The client then begins to shout and toss small objects toward the nurse. Which defense mechanism should the nurse recognize the client is displaying?

7 :
A client with bipolar disorder receives a new prescription for carbamazepine. Which action should the nurse perform before administering the medication?

8 :
After receiving treatment for anorexia nervosa, a student asks the school nurse for permission to work in the school cafeteria as part of the school's work study program. Which action should the nurse take?

9 :
A client with bipolar 1 disorder starts to sing loudly and dance around the dining area disturbing other clients. Which intervention should the nurse implement first?

10 :
A client with borderline personality disorder tells the nurse, "You are the best nurse on the unit! The other nurses don't care about me the way you do." Which response should the nurse provide to this client?