Extract:

Question 1 of 5

The nurse is teaching two nursing assistants who are new to the inpatient unit about caring for a client who is suicidal. The nurse determines that additional teaching is needed when which of the following statements is made?

Correct Answer: C

Rationale: One-to-one precautions require constant observation, not intermittent checks.

Question 2 of 5

When conducting a mental status examination with a newly admitted client who has an Axis I diagnosis of paranoid schizophrenia, the client states, 'I'm being followed; it's not safe. They're monitoring my every move.' In which of the following areas of the mental status examination should be the mental status examined.

A. Thought content. B. Quality of speech. C. Insight. D. Judgment.

Correct Answer: A

Rationale: The client's statement reflects paranoid delusions, which are assessed under thought content in a mental status examination, as this area evaluates the presence of delusions or hallucinations.

Question 3 of 5

The nurse is teaching two nursing assistants who are new to the inpatient unit about caring for a client who is suicidal. The nurse determines that additional teaching is needed when which of the following statements is made?

A. I need to check the client precisely at 15-minute intervals.' B. Documenting suicide checks is absolutely necessary.' C. A client on one-to-one suicide precautions can never be left alone.' D. All clients using razors must be supervised by staff.'

Correct Answer: C

Rationale: One-to-one precautions require constant observation, not intermittent checks.

Question 4 of 5

The client is feeling better as the symptoms of alcohol withdrawal abate. She refuses information about alcohol rehabilitation and states, 'I don't have a problem. I'll never drink like that again. I learned my lesson this time. I guess I'll just have to switch to beer or wine.' The nurse should respond by:

A. Discussing trouble. B. Explaining the effects of drinking on her family. C. Urging her to attend Alcoholics Anonymous meetings. D. Telling her about the physiologic damage that can result.

Correct Answer: C

Rationale: Urging her to attend Alcoholics Anonymous meetings is most appropriate, as it encourages ongoing support and addresses her denial, promoting long-term recovery.

Question 5 of 5

A client commonly jumps when spoken to and reports feeling uneasy. The client says, 'It's as though something bad is going to happen.' In which order from first to last should the following nursing actions be done?