Question

A client undergoing burn debridement states, "You are the worst nurse I have ever seen. All you do is hurt me." Which of the following responses should the nurse make?

Answer 1

Correct Answers:

"Tell me more about that."

Rationale :

🔶 This response uses therapeutic communication by encouraging the client to express feelings without judgment.

🔶 Burn debridement is painful and emotionally distressing, so emotional outbursts may occur.

🔶 Validating the client's experience helps the nurse maintain trust and reduce agitation.

🔶 It shifts the focus to the client’s underlying emotions, rather than reacting to the verbal attack.

🔶 This supports emotional processing and strengthens the therapeutic alliance.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Increasing feelings of anger.

Rationale :

🟡 PTSD often includes symptoms of hyperarousal, such as irritability, anger outbursts, and exaggerated startle response.

🟡 Anger may be triggered by perceived threats or reminders of the traumatic event.

🟡 This reaction is part of the body’s prolonged stress response following trauma.

🟡 The nurse should assess for safety risks due to increased aggression or self-harm potential.

🟡 Recognizing this behavior helps inform treatment planning and crisis prevention.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Schizophrenia.
Alcohol use disorder.
Substance use disorder.
Age greater than 65 years old.

Rationale :

Schizophrenia

🔷 Clients with schizophrenia are at high risk for suicide due to hallucinations, delusions, and disorganized thinking.

🔷 They may experience command hallucinations, which can instruct them to harm themselves.

🔷 Feelings of hopelessness, isolation, or fear of lifelong illness also increase suicide risk.

🔷 Risk is particularly high after a recent diagnosis or during the early stages of treatment.

🔷 Continuous mental health support and monitoring are crucial to reduce suicide risk.

Alcohol use disorder

🔷 Alcohol lowers inhibitions and increases impulsivity, making suicidal actions more likely.

🔷 It also contributes to depressive symptoms and emotional instability.

🔷 Clients may use alcohol as a maladaptive coping strategy during emotional crises.

🔷 Alcohol impairs judgment and problem-solving abilities, reducing protective factors.

🔷 Ongoing alcohol use is a major contributor to both attempted and completed suicides.

Substance use disorder

🔷 Substance use alters neurotransmitter balance, leading to mood dysregulation and impulsivity.

🔷 Clients often struggle with co-occurring depression, anxiety, or trauma, intensifying suicide risk.

🔷 Withdrawal symptoms or overdose attempts may be deliberate or accidental forms of self-harm.

🔷 The disinhibiting effects of substances impair rational thinking and coping skills.

🔷 Treatment must include integrated care plans targeting both substance use and mental health.

Age greater than 65 years old

🔷 Older adults face grief, social isolation, chronic illness, and pain, all of which contribute to suicide risk.

🔷 They may feel like a burden or experience loss of purpose after retirement or death of loved ones.

🔷 Suicide attempts in this age group are often more lethal and carefully planned.

🔷 They are also less likely to seek mental health support, making prevention more difficult.

🔷 Routine screening for depression and suicidality in older adults is essential in all care settings.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Personality Disorder.
Depression.
Obsessive-compulsive disorder (OCD).
Anxiety.

Rationale :

Personality Disorder

🔹 Personality disorders, especially borderline personality disorder, are frequently comorbid with eating disorders.

🔹 These clients often struggle with impulsivity, unstable self-image, and emotional dysregulation, which can worsen disordered eating patterns.

🔹 Maladaptive coping behaviors such as bingeing, purging, or restrictive eating may be attempts to manage interpersonal conflict or emotional pain.

🔹 Coexistence of these disorders complicates treatment and may require dialectical behavior therapy (DBT) or integrated care.

🔹 Early recognition of personality pathology can improve treatment planning and prognosis in eating disorder recovery.

Depression

🔹 Depression is one of the most common comorbidities in individuals with eating disorders.

🔹 Clients may present with low self-worth, guilt, fatigue, and suicidal ideation, complicating their nutritional status and motivation for recovery.

🔹 Malnourishment itself can worsen neurochemical imbalances, exacerbating depressive symptoms.

🔹 Addressing both nutritional rehabilitation and mood stabilization is critical for long-term recovery.

🔹 Untreated depression may lead to relapse, poor treatment adherence, or self-harm.

Obsessive-Compulsive Disorder (OCD)

🔹 OCD often coexists with anorexia nervosa and other eating disorders due to shared features like rituals, perfectionism, and rigid control.

🔹 Clients may demonstrate compulsive calorie counting, excessive exercising, or ritualized eating behaviors.

🔹 These behaviors reduce anxiety in a similar manner to compulsions seen in OCD.

🔹 Comorbid OCD requires targeted interventions such as cognitive-behavioral therapy (CBT) and possibly SSRIs.

🔹 Recognizing the compulsive component is essential to address underlying anxiety-driven behaviors.

Anxiety

🔹 Anxiety disorders, including generalized anxiety and social anxiety, are highly prevalent in clients with eating disorders.

🔹 Disordered eating behaviors may serve as maladaptive strategies to cope with chronic worry, fear of judgment, or emotional overwhelm.

🔹 Clients often experience heightened body image concerns and fear of weight gain, driving dietary restriction or purging.

🔹 Managing anxiety with psychotherapy, relaxation techniques, and medication improves treatment adherence and reduces relapse risk.

🔹 Integrated care that addresses both anxiety and disordered eating results in more successful outcomes.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

"Use a reliable form of contraception while taking this medication."

Rationale :

Alprazolam is a benzodiazepine, and its use during pregnancy may cause fetal abnormalities or withdrawal in the newborn.
Women of childbearing age should be advised to use reliable birth control to prevent pregnancy.
The nurse’s role includes ensuring informed medication use to prevent teratogenic effects.
Safe practice involves client education on reproductive risks associated with psychiatric medications.
Clients should also be informed to consult their provider before discontinuing or adjusting the dose.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

"The ritualistic behavior temporarily relieves anxiety."

Rationale :

💠 Clients with OCD perform compulsions (rituals) to reduce anxiety triggered by obsessions.

💠 The behaviors offer temporary relief but do not eliminate the source of anxiety.

💠 Understanding this helps guide care, including CBT and exposure-response prevention therapy.

💠 Nurses should avoid interrupting rituals abruptly, as this can escalate anxiety and distress.

💠 Psychoeducation helps clients learn healthier ways of coping with anxiety.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

"It's okay to feel scared. Let's talk about what you are afraid of."

Rationale :

🌟 This response uses therapeutic communication, encouraging the client to express their fears and emotional concerns before surgery.

🌟 It acknowledges that fear and regret are normal emotional reactions and invites open dialogue.

🌟 Addressing emotional distress promotes psychological readiness for surgery and enhances trust in the care team.

🌟 It avoids false reassurance or self-disclosure, focusing entirely on the client’s experience.

🌟 The nurse’s role is to provide emotional support and foster a safe space for verbal expression of concerns.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Protecting the client from injury

Rationale :

🛡️ During acute anxiety or crisis, the highest priority is safety, as clients may be at risk for self-harm or impulsive behaviors.

🛡️ Anxiety can impair judgment, increasing the potential for accidental or intentional injury.

🛡️ The nurse must act quickly to remove harmful objects, stay with the client, and ensure a secure, low-stimulus environment.

🛡️ While emotional support and exploring coping strategies are important, safety is always the first concern.

🛡️ This action aligns with Maslow’s hierarchy of needs, prioritizing physiological and safety needs before psychological concerns.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Male gender.
Age greater than 55.
Diagnosis of schizophrenia.

Rationale :

Male gender

🔷 Males have a higher suicide completion rate compared to females, primarily due to the use of more lethal means (e.g., firearms).

🔷 Men are often less likely to seek help for mental health issues, leading to underdiagnosed and untreated depression.

🔷 The societal pressure to appear strong and self-reliant may result in emotional suppression, increasing suicide risk.

🔷 Suicide in men is especially high in middle-aged and older populations, with social isolation often playing a contributing role.

Age greater than 55

🔷 Older adults face increased suicide risk due to factors such as chronic illness, grief, loss of independence, and social isolation.

🔷 Suicide attempts in this group are more likely to be lethal and well-planned compared to younger populations.

🔷 Many older adults experience untreated depression, which is often mistaken as a normal part of aging.

🔷 This population may also have limited access to mental health services or may be reluctant to use them due to stigma.

Diagnosis of schizophrenia

🔷 Individuals with schizophrenia have a suicide risk approximately 20 times greater than the general population.

🔷 Suicide is often related to psychosis, command hallucinations, delusions, or feelings of hopelessness about their condition.

🔷 Risk is particularly high during the first few years after diagnosis and following psychiatric hospitalization.

🔷 Close monitoring, medication adherence, and psychotherapy are essential in suicide prevention for these clients.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Administer the morning dose of lithium.

Rationale :

✅The therapeutic serum level of lithium for maintenance therapy is 0.6 to 1.2 mEq/L. A level of 1.0 mEq/L is well within this range and indicates safe ongoing use.

✅Since the client has been taking lithium for 2 weeks, steady-state plasma levels are expected. Continued administration is appropriate while monitoring for adverse effects.

✅ Toxic levels of lithium generally start at 1.5 mEq/L or higher. At 1.0 mEq/L, no immediate concern exists unless the client shows clinical signs of toxicity (e.g., tremor, nausea, diarrhea, or confusion).

✅Consistent dosing is essential because abrupt discontinuation of lithium can cause relapse of mood symptoms or mood destabilization, especially in bipolar clients.

✅ The nurse should administer the medication as prescribed while educating the client to maintain adequate hydration and avoid NSAIDs, which can increase lithium levels.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 :
A client undergoing burn debridement states, "You are the worst nurse I have ever seen. All you do is hurt me." Which of the following responses should the nurse make?

2 :
A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?

3 :
A nurse is providing a community health education class about suicide prevention. Which of the following should the nurse identify as risk factors for suicide? (Select all that apply).

4 :
A nurse is discussing comorbidities associated with eating disorders with a newly admitted client. Which of the following conditions should the nurse include in the discussion? (Select all that apply.)

5 :
A mental health nurse is teaching a female client who has an anxiety disorder about alprazolam. Which of the following information should the nurse include in the teaching?

6 :
A nurse is discussing obsessive-compulsive disorder (OCD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the underlying reason clients with OCD perform ritualistic behaviors?

7 :
A nurse is assessing a client who is about to undergo a left lobectomy to treat lung cancer. The client expresses fear and regret about her past smoking habit. How should the nurse respond?

8 :
A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions should be the nurse's highest priority?

9 :
A nurse manager is discussing suicide with nursing staff. Which of the following should the manager identify as risk factors for suicide? (Select all that apply.)

10 :
A nurse in an acute care mental health facility is preparing to administer morning medication to a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?

QLexNursing

1 : A client undergoing burn debridement states, "You are the worst nurse I have ever seen. All you do is hurt me." Which of the following responses should the nurse make?

2 : A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?

3 : A nurse is providing a community health education class about suicide prevention. Which of the following should the nurse identify as risk factors for suicide? (Select all that apply).

4 : A nurse is discussing comorbidities associated with eating disorders with a newly admitted client. Which of the following conditions should the nurse include in the discussion? (Select all that apply.)

5 : A mental health nurse is teaching a female client who has an anxiety disorder about alprazolam. Which of the following information should the nurse include in the teaching?

6 : A nurse is discussing obsessive-compulsive disorder (OCD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the underlying reason clients with OCD perform ritualistic behaviors?

7 : A nurse is assessing a client who is about to undergo a left lobectomy to treat lung cancer. The client expresses fear and regret about her past smoking habit. How should the nurse respond?

8 : A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions should be the nurse's highest priority?

9 : A nurse manager is discussing suicide with nursing staff. Which of the following should the manager identify as risk factors for suicide? (Select all that apply.)

10 : A nurse in an acute care mental health facility is preparing to administer morning medication to a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?

1 :
A client undergoing burn debridement states, "You are the worst nurse I have ever seen. All you do is hurt me." Which of the following responses should the nurse make?

2 :
A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?

3 :
A nurse is providing a community health education class about suicide prevention. Which of the following should the nurse identify as risk factors for suicide? (Select all that apply).

4 :
A nurse is discussing comorbidities associated with eating disorders with a newly admitted client. Which of the following conditions should the nurse include in the discussion? (Select all that apply.)

5 :
A mental health nurse is teaching a female client who has an anxiety disorder about alprazolam. Which of the following information should the nurse include in the teaching?

6 :
A nurse is discussing obsessive-compulsive disorder (OCD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the underlying reason clients with OCD perform ritualistic behaviors?

7 :
A nurse is assessing a client who is about to undergo a left lobectomy to treat lung cancer. The client expresses fear and regret about her past smoking habit. How should the nurse respond?

8 :
A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions should be the nurse's highest priority?

9 :
A nurse manager is discussing suicide with nursing staff. Which of the following should the manager identify as risk factors for suicide? (Select all that apply.)

10 :
A nurse in an acute care mental health facility is preparing to administer morning medication to a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?