Question

The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?

Answer 1

Correct Answers:

Close the examination room door for privacy.

Rationale :

🚪Ensuring privacy and confidentiality is the first and most critical step when initiating any assessment involving potential domestic violence.

🧍‍♀️Victims are unlikely to disclose abuse if they fear their abuser is nearby or could overhear the conversation.

🔐Closing the door allows the client a chance to speak freely and increases psychological safety.

📋Only after privacy is established should further assessment or protective interventions be initiated.

📌Core Message

Establishing privacy is essential to promote safety and truthful assessment in suspected domestic abuse situations.

Answer 2

Correct Answers:

Level of activity.

Rationale :

🏃‍♂️A sudden increase in activity level after starting antidepressants may indicate energized intent to act on suicidal thoughts.

⚠️This is especially dangerous in adolescents, as antidepressants can initially lift energy before improving mood.

📈Monitoring behavior patterns helps identify if the medication is having a therapeutic or dangerous effect.

📘The nurse must be vigilant for changes in energy that precede mood improvement, a known risk window.

📌Core Message

Changes in activity level are a critical indicator of suicide risk in adolescents beginning antidepressant therapy.

Answer 3

Correct Answers:

Helping clients identify areas of problem in their lives.

Rationale :

🧩The working phase of group therapy focuses on problem-solving and behavior change.

🔍This includes identifying personal challenges, setting goals, and using feedback from the group to grow.

🧠It differs from the orientation phase, which focuses on building trust, and the termination phase, which emphasizes summarizing progress.

📘Assisting clients to confront and analyze their issues is the central task of this phase.

📌Core Message

During the working phase, the focus is on identifying and addressing personal problems through group support.

Answer 4

Correct Answers:

Risk for self-directed violence related to impulsive behavior.

Rationale :

⚠️Impulsivity, poor sleep, weight loss, and erratic behavior in a manic state greatly increase the risk of self-harm or suicide.

💥The combination of impulsivity and hyperactivity makes this the most urgent concern, over nutrition or sleep.

🧠Manic episodes often involve poor judgment and reduced inhibition, further escalating risk.

📋Identifying and addressing safety risks takes priority in psychiatric care.

📌Core Message

Impulsive behavior in mania elevates the risk for self-directed violence, making it the highest priority.

Answer 5

Correct Answers:

Disturbed sensory perception.

Rationale :

👂The client is expressing grandiose and paranoid delusions, which are forms of distorted perception of reality.

🧠This indicates psychotic thinking, commonly addressed under the diagnosis of disturbed sensory perception.

🧬Other options relate to social or sexual functioning, but the core issue here is altered thought content.

📘Addressing these delusions is essential to ensure appropriate safety and treatment measures.

📌Core Message

Disturbed sensory perception reflects delusional thinking such as grandiosity or paranoia.

Answer 6

Correct Answers:

Encourage activities that allow the client to exert control over his environment.

Rationale :

🛠️Losses in multiple life areas may leave the client feeling powerless, so promoting control and decision-making is therapeutic.

🧠Allowing participation in small, achievable choices supports rebuilding self-efficacy.

📈This is particularly important after suicide attempts, when empowerment fosters recovery.

📋Avoiding or suppressing emotions may worsen outcomes; instead, healthy re-engagement is essential.

📌Core Message

Promoting control over decisions enhances emotional recovery following major life stressors.

Answer 7

Correct Answers:

Photographs

Rationale :

📷Photographic documentation of injuries provides clear, objective evidence that may be used in both clinical and legal contexts.

📘While client feelings and partner statements are relevant, they lack the forensic accuracy of visual proof.

📋Photographs should be taken with consent, ideally using institutional protocols.

🛡️Accurate injury documentation protects both the client and the healthcare team in intimate partner violence cases.

📌Core Message

Photographs provide objective, reliable documentation of injuries in IPV cases.

Answer 8

Correct Answers:

Abnormal Involuntary Movement Scale (AIMS)

Rationale :

🧠The AIMS tool is specifically used to monitor for tardive dyskinesia, a potential long-term side effect of psychotropic medications.

😛Symptoms like tongue protrusion and hand movements indicate possible extrapyramidal symptoms (EPS).

📘Reviewing prior AIMS scores helps evaluate the progression or emergence of abnormal movements.

🔍It is more targeted than general health records or labs for this symptom set.

📌Core Message

The AIMS scale is used to assess for involuntary movements caused by antipsychotic medications.

Answer 9

Correct Answers:

Take the medication each morning beginning 48 hours after your last drink of alcohol.

Rationale :

🧪Disulfiram inhibits alcohol metabolism, causing serious reactions if alcohol is consumed.

⏱️To prevent disulfiram-alcohol reaction, it should be started at least 48 hours after the last drink.

📅Morning dosing supports adherence and monitoring in structured settings.

📋Clients must receive clear guidance on timing and alcohol avoidance for safety.

📌Core Message

Disulfiram must be started 48 hours after alcohol cessation to prevent dangerous reactions.

Answer 10

Correct Answers:

Have the feelings associated with these events brought you to the clinic?

Rationale :

🧠This question redirects the conversation to emotional impact, encouraging insight and therapeutic dialogue.

📘It is open-ended and non-judgmental, avoiding defensiveness while exploring motivation.

🧍‍♂️This approach allows the client to reflect on how external events led to emotional distress.

📋It is more therapeutic than offering advice or challenging perceptions.

📌Core Message

Exploring emotional impact of life events supports therapeutic assessment and trust-building.

1 :
The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?

2 :
An adolescent who is exhibiting a depressed affect receives a prescription for an antidepressant drug. While the client is taking the antidepressant, which comparison of the client's behavior before and after taking the drug is most important for the nurse to obtain?

3 :
The nurse is leading a group on the inpatient psychiatric unit. Which approach should the nurse use during the working phase of group development?

5 :
A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

7 :
The nurse completes an assessment of a client experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?

8 :
When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client's record should the nurse review?

9 :
A client who is an alcoholic receives a prescription for disulfiram 500 mg PO daily. Which instruction should the nurse provide to this client?

1 : The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?

2 : An adolescent who is exhibiting a depressed affect receives a prescription for an antidepressant drug. While the client is taking the antidepressant, which comparison of the client's behavior before and after taking the drug is most important for the nurse to obtain?

3 : The nurse is leading a group on the inpatient psychiatric unit. Which approach should the nurse use during the working phase of group development?

5 : A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

7 : The nurse completes an assessment of a client experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?

8 : When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client's record should the nurse review?

9 : A client who is an alcoholic receives a prescription for disulfiram 500 mg PO daily. Which instruction should the nurse provide to this client?

1 :
The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?

2 :
An adolescent who is exhibiting a depressed affect receives a prescription for an antidepressant drug. While the client is taking the antidepressant, which comparison of the client's behavior before and after taking the drug is most important for the nurse to obtain?

3 :
The nurse is leading a group on the inpatient psychiatric unit. Which approach should the nurse use during the working phase of group development?

5 :
A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

7 :
The nurse completes an assessment of a client experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?

8 :
When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client's record should the nurse review?

9 :
A client who is an alcoholic receives a prescription for disulfiram 500 mg PO daily. Which instruction should the nurse provide to this client?