A client actively involved in substance addiction therapy frequently relapses into
benzodiazepines and alcohol use. The client tells the nurse, "I don't think I will ever be able
to kick this habit." How should the nurse respond? - ANSWER>>The client must participate
in making decisions about one's own physical and mental health.
A client is pacing in the hall near the nurses' station and swearing loudly. What response is
best for the nurse to provide? - ANSWER>>You seem pretty upset. Tell me about it.
A client is responding to auditory hallucinations and shakes a fist at a nurse and says, "Back
off, witch!" The nurse follows the client to the unit's day room. What action should the nurse
implement? - ANSWER>>Ensure that there is physical space between the nurse and client.
A client is scheduled to complete a positron emission tomography (PET) scan. The client asks
the nurse to explain the reason the test was prescribed. How should the nurse respond? -
ANSWER>>Results show activity in various portions of the brain.
A client is told that her infant will be stillborn. What is the most important action for the
nurse to implement after the birth? - ANSWER>>Ask the family if they would like to see and
hold the infant after birth.
A client on the mental health unit reports concerns about weight gain as a result of taking
divalproex (Depakote) and requests assistance to fill out a menu. The nurse should initiate a
referral to which healthcare team member? - ANSWER>>Dietician.
A client who abuses alcohol says to the nurse, "I am glad I went in for treatment. Now my
problems with alcohol are all behind me." Which response is best for the nurse to provide? -
, ANSWER>>Tell me more about what you mean when you say that your problems with
alcohol are now behind you
A client who had a miscarriage at 10-weeks gestation tells the nurse that she already
purchased some baby things and picked out a name. After the surgical dilation and curettage
(D&C), the client wants to go home as soon as possible. Based on the client's statements,
which action should the nurse implement? - ANSWER>>Ask the client what name she had
picked out for the infant.
A client who is intoxicated is admitted for alcohol and multiple substance detoxification. The
nurse determines that the client is becoming increasingly anxious, agitated, and diaphoretic.
The client is also experiencing sensory perceptual disturbances and a clouded sensorium.
What is the priority nursing intervention for this client at this time? - ANSWER>>Begin one-
on-one supervision immediately.
A client who reports feeling depressed tells the nurse on admitted, "I want to feel normal
again." How should the nurse respond? - ANSWER>>"Tell me more about how things are
with you."
A client with a history of alcoholism is admitted with a compound fracture of the femur after
falling down the previous night. What additional assessment should be the priority focus for
the nurse? - ANSWER>>Ask the client about the quantity, frequency, and time the last
alcohol drink was ingested.
A client with panic disorder tells the nurse, "This illness is awful. I'm frightened that I will
always be this way and that there's no hope for me." What information should the nurse
provide? - ANSWER>>Panic disorder is treatable in a number of different ways, including
medication.
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