Question

For which of the following clients is a nurse considered a mandated reporter to the appropriate agency?

Answer 1

Correct Answers:

A client who reports that their partner ties their child to a bed as punishment.

Rationale :

🔴 Nurses are legally mandated reporters and must report suspected child abuse immediately to the appropriate agency.

🔴 Tying a child to a bed constitutes physical abuse and unlawful restraint, even if the parent believes it's a form of punishment.

🔴 The nurse does not need proof—reasonable suspicion is sufficient to file a report.

🔴 Reporting protects the child from further harm and initiates an investigation by child protective services (CPS).

🔴 Failure to report can result in legal consequences and license disciplinary action for the nurse.

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Answer 2

Correct Answers:

Identify prior coping skills

Rationale :

🟡 In crisis intervention, the first priority is to assess the client's coping mechanisms and psychological stability.

🟡 Knowing what strategies were effective during previous stressful events can help guide immediate support.

🟡 This assessment also helps the nurse evaluate adaptive vs. maladaptive responses, which is crucial in grief processing.

🟡 Adolescents coping with trauma such as a peer’s suicide may exhibit various emotional responses; thus, starting with known strengths is therapeutic.

🟡 Once coping ability is understood, the nurse can implement appropriate referrals and resources.

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Answer 3

Correct Answers:

The client develops an inability to concentrate.

Rationale :

🔷 An inability to concentrate is one of the early warning signs of schizophrenia relapse.

🔷 It often occurs before the re-emergence of hallucinations or delusions, making it a vital symptom for families to monitor.

🔷 Identifying this symptom allows for early intervention, potentially preventing full relapse or hospitalization.

🔷 This information helps family members recognize when to seek medical help or adjust treatment.

🔷 Including this in discharge teaching ensures caregivers are proactive in relapse prevention.

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Answer 4

Correct Answers:

A client who has bipolar disorder and is exhibiting poor impulse control.

Rationale :

🟣 Poor impulse control in a bipolar client, especially during a manic phase, poses a serious risk to safety.

🟣 Clients may engage in risky behaviors such as spending sprees, aggression, or sexual promiscuity.

🟣 The plan of care must be updated to reflect interventions like close monitoring, limit-setting, and possible medication adjustment.

🟣 Failing to address these behaviors can result in harm to the client or others.

🟣 Safety concerns always take precedence in mental health care planning.

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Answer 5

Correct Answers:

Offer to talk with the caregiver about their feelings.

Rationale :

🟢 The caregiver's behavior—crying and throwing magazines—indicates emotional distress and caregiver burnout.

🟢 The nurse should first offer emotional support to help the caregiver feel heard and validated.

🟢 This builds rapport and provides an opening to assess for depression, anxiety, or stress-related fatigue.

🟢 Only after this conversation should the nurse proceed to interventions like support group referrals or relaxation techniques.

🟢 Immediate emotional support helps prevent caregiver crisis or breakdown.

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Answer 6

Correct Answers:

Determine if the client has thoughts of harming themselves.

Rationale :

🔶 The sudden loss of a child is a major emotional trauma that increases risk of suicidal ideation.

🔶 The nurse’s first priority is to assess the client’s safety by asking directly about thoughts of self-harm.

🔶 If the client endorses suicidal ideation, immediate intervention is required, including possible hospitalization.

🔶 Without ruling out harm, other actions like coping education or planning are inappropriate and premature.

🔶 This action aligns with Maslow’s hierarchy, prioritizing physiological and safety needs first.

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Answer 7

Correct Answers:

St. John's wort

Rationale :

🟠 St. John's wort interacts with fluoxetine (an SSRI) and can cause serotonin syndrome, a potentially life-threatening condition.

🟠 Symptoms may include agitation, tremors, confusion, and hyperreflexia, requiring urgent medical attention.

🟠 The nurse should instruct the client to avoid combining serotonergic substances without provider guidance.

🟠 Herbal supplements are often perceived as safe, so educating clients about drug-herb interactions is critical.

🟠 Preventing serotonin syndrome is a key safety priority in pharmacologic education.

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Answer 8

Correct Answers:

Document the client's refusal of the treatment in the medical record.

Rationale :

🟤 Even if a client is involuntarily committed, they retain the right to refuse treatments like ECT unless a legal override exists.

🟤 The nurse must respect the client’s autonomy and record the refusal accurately in the medical record.

🟤 Documentation is essential for legal protection and maintaining professional standards of care.

🟤 The nurse should also inform the provider, but documentation is the immediate and appropriate nursing action.

🟤 Forcing treatment without consent violates ethical principles and patient rights.

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Answer 9

Correct Answers:

"l will let the provider know about your decision to refuse the treatment."

Rationale :

⚪ This response is respectful, acknowledges the client’s right to autonomy, and ensures proper communication with the provider.

⚪ The client has expressed withdrawal of consent, and the nurse should not coerce or pressure them to continue.

⚪ Informing the provider allows for re-evaluation of the treatment plan and consideration of alternatives.

⚪ Therapeutic communication supports a trusting nurse-client relationship while also meeting ethical standards.

⚪ Clients must feel that their voice and decisions are respected, even in psychiatric settings.

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Answer 10

Correct Answers:

Decreased libido

Rationale :

🧬 Citalopram, an SSRI, commonly causes sexual side effects, including decreased libido, delayed orgasm, or anorgasmia.

🧬 These effects are dose-dependent and can affect treatment adherence if not discussed with the client.

🧬 Nurses should educate clients to report these changes, as dosage adjustments or alternative medications may be considered.

🧬 It’s important to normalize the conversation around sexual side effects to promote open communication.

🧬 Monitoring and managing side effects helps maintain treatment compliance and client satisfaction.

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QLexNursing

1 :
For which of the following clients is a nurse considered a mandated reporter to the appropriate agency?

2 :
A nurse is leading a crisis intervention group for adolescents who witnessed the suicide of a classmate. Which of the following actions should the nurse take first?

3 :
A nurse is providing discharge teaching about the manifestations of relapse to the family of a client who has schizophrenia. Which of the following information should the nurse include in the teaching?

4 :
A nurse in a mental health facility is caring for a group of clients. After assessing the clients, which of the following clients requires an update to their plan of care to ensure client safety?

5 :
A nurse observes the caregiver of a client who has Alzheimer's disease throwing magazines on the floor and crying. Which of the following actions should the case manager take first?

6 :
A nurse is caring for a client who is experiencing a situational crisis following the sudden loss of their adolescent child. Which of the following actions should the nurse take first?

7 :
A nurse is teaching a client who is about to start taking fluoxetine. The nurse should instruct the client that which of the following supplements interacts adversely with fluoxetine?

8 :
A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the healthcare team. Which of the following actions should the nurse take?

9 :
A nurse is caring for a client who is scheduled for electroconvulsive treatment (ECT). The client states, "l no longer want to have the treatment." Which of the following statements would be an appropriate response from the nurse?

10 :
For which of the following adverse effects should a nurse monitor a client taking citalopram?

QLexNursing

1 : For which of the following clients is a nurse considered a mandated reporter to the appropriate agency?

2 : A nurse is leading a crisis intervention group for adolescents who witnessed the suicide of a classmate. Which of the following actions should the nurse take first?

3 : A nurse is providing discharge teaching about the manifestations of relapse to the family of a client who has schizophrenia. Which of the following information should the nurse include in the teaching?

4 : A nurse in a mental health facility is caring for a group of clients. After assessing the clients, which of the following clients requires an update to their plan of care to ensure client safety?

5 : A nurse observes the caregiver of a client who has Alzheimer's disease throwing magazines on the floor and crying. Which of the following actions should the case manager take first?

6 : A nurse is caring for a client who is experiencing a situational crisis following the sudden loss of their adolescent child. Which of the following actions should the nurse take first?

7 : A nurse is teaching a client who is about to start taking fluoxetine. The nurse should instruct the client that which of the following supplements interacts adversely with fluoxetine?

8 : A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the healthcare team. Which of the following actions should the nurse take?

9 : A nurse is caring for a client who is scheduled for electroconvulsive treatment (ECT). The client states, "l no longer want to have the treatment." Which of the following statements would be an appropriate response from the nurse?

10 : For which of the following adverse effects should a nurse monitor a client taking citalopram?

1 :
For which of the following clients is a nurse considered a mandated reporter to the appropriate agency?

2 :
A nurse is leading a crisis intervention group for adolescents who witnessed the suicide of a classmate. Which of the following actions should the nurse take first?

3 :
A nurse is providing discharge teaching about the manifestations of relapse to the family of a client who has schizophrenia. Which of the following information should the nurse include in the teaching?

4 :
A nurse in a mental health facility is caring for a group of clients. After assessing the clients, which of the following clients requires an update to their plan of care to ensure client safety?

5 :
A nurse observes the caregiver of a client who has Alzheimer's disease throwing magazines on the floor and crying. Which of the following actions should the case manager take first?

6 :
A nurse is caring for a client who is experiencing a situational crisis following the sudden loss of their adolescent child. Which of the following actions should the nurse take first?

7 :
A nurse is teaching a client who is about to start taking fluoxetine. The nurse should instruct the client that which of the following supplements interacts adversely with fluoxetine?

8 :
A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the healthcare team. Which of the following actions should the nurse take?

9 :
A nurse is caring for a client who is scheduled for electroconvulsive treatment (ECT). The client states, "l no longer want to have the treatment." Which of the following statements would be an appropriate response from the nurse?

10 :
For which of the following adverse effects should a nurse monitor a client taking citalopram?