Question 1 of 5

The client with recurrent depression and suicidal ideation tells the nurse, 'I can't afford this medicine anymore. I know I'll be okay without it.' The nurse should:

A. Inform the physician of the client's statement.B. Ask the social worker to find assistance for the client.C. Schedule a follow-up appointment in 3 months.D. Ask the client whether a family member could help.

Correct Answer: A

Rationale: Informing the physician ensures timely intervention to address affordability and prevent relapse.

Question 2 of 5

In an ongoing assessment, the nurse should identify the client's thoughts and feelings about a situation in addition to which of the following?

A. Whether the client's behavior is appropriate in the context of the current situation.B. Whether the client is motivated to decrease dysfunctional behaviors.C. Which of the client's problems have the highest priority.D. Which of the client's behaviors necessitates a no harm contract.

Correct Answer: A

Rationale: Assessing whether the client's behavior is appropriate in the context provides critical information about their coping and mental state, complementing thoughts and feelings. Motivation, priority of problems, and need for a no harm contract are important but secondary to understanding behavior in context for ongoing assessment.

Question 3 of 5

The nurse is required initially to restrain all four of a client's extremities. For which of the following reasons should the nurse anticipate the need to add a full-length restraint blanket?

A. The client complains that restraints are tight and uncomfortable.B. The staff want extra protection for themselves.C. The client is at risk for injury from fighting the restraints.D. Staff assessment reveals that the client will feel more secure under the blanket.

Correct Answer: C

Rationale: A full-length restraint blanket is used if the client is at risk for injury from fighting restraints, as it provides additional security to prevent harm. Client discomfort, staff protection, or perceived security are not primary indications for its use.

Question 4 of 5

A client with dementia is agitated in the evening. Which term describes this behavior?

A. SundowningB. DeliriumC. PsychosisD. Apathy

Correct Answer: A

Rationale: Sundowning refers to increased agitation in the evening, common in dementia, requiring targeted interventions.

Question 5 of 5

At 10 a.m., a client with an Axis I diagnosis of pain disorder demands that the nurse call the physician for more pain medication because she's still in pain after the 9 a.m. analgesic. Which of the following should the nurse do next?

A. Call the physician as the client requests.B. Suggest the client lie down while she is waiting for her next dose.C. Tell the client that the physician will be in later to talk to her about it.D. Inform the client that the nurse cannot give her additional medication at this time.

Correct Answer: D

Rationale: Informing the client that additional medication cannot be given now is appropriate, as it sets limits, adheres to the medication schedule, and encourages non-pharmacologic pain management.