Question

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

Answer 1

Correct Answers:

Focus on small achievable tasks, not taxing problems.

Rationale :

🟢 Clients with depression often struggle with feelings of helplessness, low self-worth, and impaired decision-making, making large or complex tasks feel overwhelming.

🟢 Encouraging the client to focus on small, realistic, and achievable goals helps re-establish a sense of control and confidence, which is essential in the early stages of recovery.

🟢 This method reduces the risk of frustration and failure, which could otherwise reinforce depressive thoughts and inactivity.

🟢 Over time, achieving small goals builds momentum for re-engagement in daily life, enhancing both mood and functioning.

🟢 It aligns with cognitive-behavioral therapy principles, which emphasize incremental progress as a strategy for managing depression.

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Answer 2

Correct Answers:

Returns to her previous level of functioning.

Rationale :

🟡 In acute psychiatric care, especially after a suicide attempt, the primary goal is stabilization, focusing on ensuring safety and helping the client regain previous psychosocial functioning.

🟡 While identifying strengths or developing new coping mechanisms are useful, they are secondary to restoring the client’s ability to perform basic life roles and routines.

🟡 This outcome measures whether the intervention helped the client recover to her pre-crisis mental health baseline.

🟡 It ensures readiness for discharge and sets the stage for continued outpatient therapy and recovery planning.

🟡 Nursing care should prioritize function restoration, not just emotional exploration, during hospitalization.

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Answer 3

Correct Answers:

Returns to her previous level of functioning.

Rationale :

🟢 Repetition of this question highlights the consistent priority in psychiatric hospitalization: achieving a stable and safe psychological state from which the client can rebuild.

🟢 Restoring functional capacity—such as returning to school or managing relationships—indicates progress in managing depression and suicidal ideation.

🟢 Emotional expression and exploration are part of therapy, but are most effective after stabilization is achieved.

🟢 Measurable outcomes like "returning to previous functioning" help guide treatment planning and discharge readiness.

🟢 This clinical goal aligns with the nursing process: assess → plan → intervene → evaluate recovery.

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Answer 4

Correct Answers:

Spend time sitting in silence with the client.

Rationale :

🔵 Clients with major depression may demonstrate psychomotor retardation, which includes slow response times, limited speech, and reduced movement.

🔵 Silence in therapeutic communication is not passive; it allows the client to feel safe and unpressured, giving time to process emotions and formulate responses.

🔵 The nurse’s presence, even in silence, offers emotional support and reassurance without demanding verbal participation.

🔵 This strategy communicates acceptance and helps establish trust and rapport, especially important in depressive states.

🔵 Forcing verbal interaction or dismissing silence can increase the client’s anxiety or feelings of inadequacy.

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Answer 5

Correct Answers:

Explain that opioid receptor response reduces with continued use.

Rationale :

🟣 The client’s statement indicates tolerance, a key concept in substance dependence, where the body becomes less responsive to the same dose of a drug.

🟣 Educating the client about neurobiological adaptation helps normalize their experience and opens the door to discussions about alternatives or treatment planning.

🟣 Understanding tolerance supports the client in making informed decisions about pain management and the risks of dependency.

🟣 This approach is nonjudgmental and therapeutic—it respects the client's experience while introducing evidence-based education.

🟣 The nurse can then assess for possible misuse or withdrawal symptoms and collaborate with the healthcare provider for appropriate treatment.

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Answer 6

Correct Answers:

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

Rationale :

🟢 The client with borderline personality disorder (BPD) is demonstrating splitting, a defense mechanism characterized by idealizing one caregiver and devaluing others.

🟢 The nurse's response should emphasize the team approach and set clear therapeutic boundaries while still validating the client’s emotional needs.

🟢 This answer avoids reinforcing the splitting behavior, which can lead to disruption in care continuity and team conflict.

🟢 It reminds the client that all staff are committed to providing consistent and professional care.

🟢 Maintaining neutrality and reinforcing team unity is essential to managing clients with BPD effectively.

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Answer 7

Correct Answers:

Mail education items to the home for batterer treatment options
Provide referrals from the physician for mental health services
Document verbatim statements about the abuse

Rationale :

🟡 A. Mailing educational items ensures that the client receives non-confrontational support resources in a safe manner, especially in cases of intimate partner violence (IPV).

🟡 B. Referrals from a physician legitimize the care pathway and provide access to mental health and trauma counseling services.

🟡 E. Verbatim documentation is critical in IPV situations—it ensures that the client’s exact words are preserved for legal or clinical purposes, avoiding misinterpretation.

🟡 Actions like calling the police (D) may be inappropriate unless mandatory reporting laws apply or there is imminent danger, and “follow-up in a few weeks” (C) may not ensure timely support.

🟡 The selected answers reflect nursing advocacy, trauma-informed care, and legal responsibility

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Answer 8

Correct Answers:

Sleeps at least six hours a night.

Rationale :

🔵 In the initial days of antidepressant treatment, priority goals address physiological restoration, particularly sleep and nutrition.

🔵 Sleep deprivation exacerbates depression, increases suicide risk, and impairs cognitive and emotional processing.

🔵 While understanding the medication is important long-term, restoring sleep promotes healing and allows medications to take effect.

🔵 Adequate rest is a foundation for emotional stability, and it also enhances medication tolerance and engagement in therapy.

🔵 Early sleep improvement is a positive prognostic sign for antidepressant efficacy.

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Answer 9

Correct Answers:

Current vital signs.

Rationale :

🟣 Neuroleptic Malignant Syndrome (NMS) is a life-threatening reaction to antipsychotic medications like haloperidol.

🟣 Early signs include hyperthermia, muscle rigidity, tachycardia, and labile blood pressure, all detected through vital sign monitoring.

🟣 Monitoring for fever and autonomic instability is essential during follow-up, especially within the first two weeks of starting or adjusting doses.

🟣 Although WBCs and other labs may be helpful, vital signs provide immediate, actionable data to detect NMS early.

🟣 Early intervention can prevent complications such as renal failure, respiratory collapse, and death.

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Answer 10

Correct Answers:

Attempt to ask the client simple questions.

Rationale :

🟠 A guarded, suspicious client likely displays paranoid features and may perceive others as threatening.

🟠 Postponing the interview or avoiding engagement can reinforce isolation or mistrust.

🟠 Approaching with simple, non-threatening questions helps build rapport while respecting the client's need for control and safety.

🟠 The nurse must proceed cautiously but consistently, demonstrating patience and respect for personal boundaries.

🟠 Gentle engagement often helps the client lower defenses and become more open over time.

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QLexNursing

1 :
A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

2 :
A female college student is admitted to the mental health unit following a drug overdose. The student tells the nurse that she took the overdose following the end of a romantic relationship. Which is the primary goal for hospitalization that should be included in this client's plan of care?

3 :
A female college student is admitted to the mental health unit following a drug overdose. The student tells the nurse that she took the overdose following the end of a romantic relationship.
Which is the primary goal for hospitalization that should be included in this client's plan of care?

4 :
When the nurse addresses questions to an adult female client who is depressed, the client's responses are delayed. Which intervention should the nurse include in this client's plan of care?

5 :
A client reports needing to increase opioid dosage to achieve the original level of pain relief. Which action should the nurse take?

6 :
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?

7 :
Following the visit, what are appropriate actions for the nurse?Select all that apply.

8 :
An antidepressant medication is prescribed for a client who reports sleeping only four hours in the past two days and a weight loss of nine pounds within the last month. Which client goal is most important to achieve within the first three days of treatment?

9 :
A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?

10 :
A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

QLexNursing

1 : A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

2 : A female college student is admitted to the mental health unit following a drug overdose. The student tells the nurse that she took the overdose following the end of a romantic relationship. Which is the primary goal for hospitalization that should be included in this client's plan of care?

3 : A female college student is admitted to the mental health unit following a drug overdose. The student tells the nurse that she took the overdose following the end of a romantic relationship.Which is the primary goal for hospitalization that should be included in this client's plan of care?

4 : When the nurse addresses questions to an adult female client who is depressed, the client's responses are delayed. Which intervention should the nurse include in this client's plan of care?

5 : A client reports needing to increase opioid dosage to achieve the original level of pain relief. Which action should the nurse take?

6 : 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?

7 : Following the visit, what are appropriate actions for the nurse?Select all that apply.

8 : An antidepressant medication is prescribed for a client who reports sleeping only four hours in the past two days and a weight loss of nine pounds within the last month. Which client goal is most important to achieve within the first three days of treatment?

9 : A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?

10 : A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

1 :
A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

2 :
A female college student is admitted to the mental health unit following a drug overdose. The student tells the nurse that she took the overdose following the end of a romantic relationship. Which is the primary goal for hospitalization that should be included in this client's plan of care?

3 :
A female college student is admitted to the mental health unit following a drug overdose. The student tells the nurse that she took the overdose following the end of a romantic relationship.
Which is the primary goal for hospitalization that should be included in this client's plan of care?

4 :
When the nurse addresses questions to an adult female client who is depressed, the client's responses are delayed. Which intervention should the nurse include in this client's plan of care?

5 :
A client reports needing to increase opioid dosage to achieve the original level of pain relief. Which action should the nurse take?

6 :
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?

7 :
Following the visit, what are appropriate actions for the nurse?Select all that apply.

8 :
An antidepressant medication is prescribed for a client who reports sleeping only four hours in the past two days and a weight loss of nine pounds within the last month. Which client goal is most important to achieve within the first three days of treatment?

9 :
A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?

10 :
A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?