Psychosocial Integrity Lippincott NCLEX-RN, PrepU

A 3-year-old child of Vietnamese descent with a fever, decreased urine output, wheezing, and coughing is brought to the emergency department. On examination, the nurse discovers red, round, welt-like lesions on the child's upper back and chest. Which question should the nurse ask next?

"Can you tell me about any cultural practices in your family?"

The parent of a toddler who has just been admitted with severe dehydration secondary to gastroenteritis says that they cannot stay with their child because they have to take care of their other children at home. Which of the responses by the nurse would be most appropriate?

"I understand, but feel free to visit or call anytime to see how your child is doing."

A client with physical deficits related to a recent cerebral vascular accident states tearfully, "I no longer can take care of myself." Which statement by the nurse is most therapeutic?

"It is hard not to be able to care for yourself."

The health care provider is preparing a plan of care for a client with borderline personality disorder. Which medication would the nurse anticipate for this client?

Selective serotonin reuptake inhibitors (SSRIs), along with an atypical antipsychotic, are used to treat mood instability and impulsivity.

A client says to a nurse, "I know I am going to die." How should the nurse respond?

"Tell me more about what you mean when you say you know you are going to die."

A client with two young children is diagnosed with breast cancer. The client says, "This is the worst time in my life. How can I adjust to all of this without losing it?" What is the nurse's best response?

"What ways have you used to help reduce stress and cope with significant events in your life?"

A client who is dying from AIDS is admitted to the inpatient psychiatric unit because they attempted suicide. Their close friend recently died from AIDS. The client states to the nurse, "What's the use of living? My time's running out." What is the nurse's best response?

"You're in a lot of pain. What are you feeling?" Explanation: The nurse recognizes the client's pain, hopelessness, and sense of loss related to their condition and the loss of their friend and encourages them to express their feelings. Giving the client permission to talk about their feelings of sadness, loss, and hopelessness and listening to them is an important nursing intervention for the dying client.Telling the client to make good use of their remaining time diverts attention from the content of the client's statements and blocks expression of feelings."Don't give up" is a type of pep talk that ignores the client's feelings.Saying that life is precious and worth living ignores the client's needs and inhibits their expression of feelings.

A nurse is caring for multiple grieving clients. Which client is most likely to experience disenfranchised grief?

A 50-year-old client whose ex-spouse died suddenly in a motor vehicle accident

Which factors should be the primary factor in a nurse's decision whether to pray with a client?

the client's openness to being prayed for

A 30-year-old client shares with the nurse that he or she has had a really hard time since the divorce 1 year ago, struggling with depression and anxiety. The client had a makeover and will be going on vacation with a best friend next month. The client has started thinking about dating again. The nurse understands that this client is in which stage of the grief process?

Acceptance

Which principle of the psychoanalytic model is particularly useful to psychiatric nurses?

All behavior has meaning.

A client has been diagnosed with colon cancer with metastasis to the lymph nodes. When the nurse enters the room, the client says life is "not worth living." What is the nurse's best therapeutic response?

Approach the client and ask if there are questions about the condition. Explanation: This is the best therapeutic response that is client focused. The other answers do not demonstrate therapeutic response: nurses should not offer false assurances, and calling the family is not addressing the problem between nurse and client.

When a client expresses feelings of unworthiness, which response by the nurse would be mostappropriate?

As you begin to feel better, your feelings of unworthiness will begin to disappear."

An adolescent girl with severe malnutrition is admitted to an acute care facility. After a thorough examination, the physician diagnoses anorexia nervosa. When developing the care plan for this client, the nurse is most likely to include which nursing diagnosis?

Chronic low self-esteem

A client's spouse expresses concern that the dying client keeps saying, "I have to go to the store." Which statement by the nurse will be most effective in assisting the spouse to understand the dying process?

Comments related to going somewhere or leaving on a trip are common in dying clients."

A client is informed by his healthcare provider that a tumor has been found. When the nurse sees the client later, the client states that no one knows what is wrong with him. The nurse determines that the client is experiencing which of the following?

Could be in denial

A female client is worried about being placed in the lithotomy position for surgery. What action should the nurse take?

Determine what the client is concerned about.

A nurse is caring for a 10-year-old child with cystic fibrosis. The parents tell the nurse that the child needs to placed in a facility that can provide more care. What action will the nurse take?

Encourage the parents to discuss what is causing the need for placement.

The nurse is caring for an elderly nursing home client who is anxious and fearful after being admitted to the hospital. Which intervention is the nursing priority?

Explain procedures and unit routines to the client, as well as checking orientation

After completing diagnostic testing, the surgeon has scheduled a newborn with the diagnosis of an imperforate anus for surgery the next day. The infant's parents do not want the surgery to take place unless the infant has first been baptized. What should the nurse ask the parents?

How can I arrange the baptism?"

Which question would the nurse ask to determine a client's coping abilities during a lengthy hospital stay?

How is this illness impacting you and your family?"

Which nursing strategy would be effective in managing a client who has Alzheimer's disease and wanders?

Involve the client in activities that promote walking.

A client has entered a smoking cessation program to quit a two-pack-a-day cigarette habit. The client has not smoked a cigarette for 3 weeks and tells the nurse about fears of starting smoking again because of current job pressures. What would be the most appropriate reply for the nurse to make in response to the client's comments?

It's good that you can talk about your concerns. Try calling a friend when you want to

The nurse is assigned to care for a client admitted with depression as well as a dependent personality disorder. Which statement by the client is indicative of this personality disorder?

Please don't forget to wait for me to go to dinner. I don't want to go by myself."

The nurse is caring for a multiparous client after vaginal birth of a set of twins 2 hours ago. What should the nurse should encourage the client and their partner to do?

Relate to each twin individually to enhance the attachment process.

A nurse manager observes bruises in the shape of finger marks around the elbows of an elderly, immobile client. The nurse should next:

Report this finding to the Adult Protective Services (APS). Explanation: Elderly clients are vulnerable to abuse. Bruising that is not located in areas typical for falls or bumps should be reported to the APS. The location and shape of this bruise are suggestive of abuse. The nurse taking care of this client and the physician should be alerted to the bruises after the APS is notified. The nurse should continue to assess the areas involved after notifying the APS.

The family of an older adult wants their mother to have counseling for depression. During the initial nursing assessment, the client denies the need for counseling. Which comment by the client supports the fact that the client may not need counseling?

Since I've gotten over the death of my husband, I've had more energy and been more active than before he died."

Assessment of a client who has just been admitted to the inpatient psychiatric unit reveals an unshaven face, noticeable body odor, visible spots on the shirt and pants, slow movements, gazing at the floor, and a flat affect. Which of the following should the nurse interpret as indicating psychomotor retardation?

Slow movements

The nurse is working in a psychiatric facility on an anxiety disorder unit. The unit is locked and clients have scheduled group and family therapy sessions. Which other standard is maintained on this unit for a client diagnosed with panic disorder?

Suicide precautions are instituted.

A client with major depression and suicidal ideation is suddenly calmer and more energetic. Which conclusion should the nurse reach?

The client is imminently suicidal. Explanation: When a client with major depression and suicidal ideation displays a sudden elevation in mood, seems calmer, has more energy, and is more peaceful, the nurse should judge these behaviors as an indication that a suicide attempt is imminent. These symptoms may indicate relief from ambivalent thoughts about suicide and that the client has an immediate plan for killing himself.

A client with a head injury regains consciousness after several days. When the client first awakes, what should the nurse say to the client?

You're in the hospital. You were in an accident and unconscious." Explanation: It is important to first explain where a client is to orient them to time, person, and place. Offering to get the family and asking questions to determine orientation are important, but the first comments should let the client know where they are and what has happened. It is useful to be empathetic to the client, but making a comment such as "I'll bet you are a little confused" is not helpful and may cause anxiety.

A nurse is taking a health history of a 10-year-old child and discovers that the child has difficulties in urinary control during the day. The parents are confused about the condition and ask the nurse for help. What is the most appropriate response by the nurse?

There may be a significant stressor in your child's life that's causing this."

A client was admitted to an inpatient psychiatric unit with a diagnosis of major depression. The client expresses feelings of worthlessness and of being abandoned by significant persons in their life. Which response by the nurse would convey empathy to the client?

This must be a difficult time for you."

A psychiatrist who has been working with a client on spirituality asks the client to read a book called, The Power of Spirituality on Thinking and Life, and to discuss it the following week. The nurse identifies this as a form of

bibliotherapy Explanation: Bibliotherapy involves the use of literature to help clients gain insight into feelings and behavior and learn new ways to cope with difficult situations. It has been identified as a process of interaction between the personality of the reader and the literature, which may be used for personality assessment, adjustment, or growth.

A client, age 22, is admitted in a psychotic episode. The client's frequent requests to speak with the hospital chaplain are interspersed with profanities regarding God and the devil. The mosttherapeutic nursing intervention would be to

continue providing safe, effective care and give anti-psychotic medications as ordered to reduce symptoms of psychosis. Explanation: Safety is the nurse's first priority. The client is experiencing altered thought processes and is unlikely to be able to distinguish his spiritual beliefs at this time.

When a nurse reflects on questions such as "Why am I here?" the nurse is attempting to

develop a philosophical base for clearer thinking.

An infant diagnosed with Hirschsprung disease is scheduled to receive a temporary colostomy. When the nurse is initially discussing the diagnosis and treatment with the parents, which action by the nurse would be most appropriate?

encouraging them to ask questions

A client with schizophrenia is admitted to the psychiatric unit of a local hospital. During the next several days, the client is seen laughing, yelling, and talking out loud to no one. This behavior is characteristic of:

hallucination

A nurse is caring for a toddler with Down syndrome. To help the toddler cope with painful procedures, the nurse can

hold and rock the child and give the child a security object. Explanation: The toddler with Down syndrome may have difficulty coping with painful procedures and may regress during illness. Holding, rocking, and giving the child a security object is helpful because it may be comforting to the child. An older child or a child without Down syndrome may benefit from positive self-talk, time limits, and diversionary tactics, such as counting and singing; however, the success of these tactics depends on the child.

The client states they wash their feet endlessly because they "are so dirty that I can't put on my socks and shoes." The nurse recognizes the client is using ritualistic behavior primarily to relieve discomfort associated with which feeling?

intolerable anxiety

A nurse is caring for a client with bipolar disorder. The care plan for a client in a manic state would include:

listening attentively to the client's requests with a neutral attitude, and avoiding power

The nurse is counseling the family of an older adult who died today. Which factor facilitates attainment of a positive bereavement outcome?

possessing adequate financial resources

A child is admitted with a tentative diagnosis of clinical depression. Which assessment finding is most significant in confirming this diagnosis?

sadness Explanation: Clinical depression is diagnosed if the child exhibits a depressed mood (sadness) or loss of interest. Irritability isn't diagnostic for depression. Although a depressed child may gain weight and report fatigue, these findings aren't essential to the diagnosis.

A nurse performing an assessment determines that a client with anorexia nervosa is currently unemployed and has a family history of affective disorders, obesity, and infertility. Based on this information, the nurse should monitor the client for which health concern?

suicide potential

A nurse plans to include the parents of a client with anorexia nervosa in the client's therapy sessions. The nurse should anticipate that the parents will:

tend to overprotect their child.

A preadolescent child is suspected of being sexually abused because they demonstrate the self-destructive behaviors of self-mutilation and attempted suicide. Which common behavior should the nurse also expect to assess?

truancy and running away

The nurse is performing an admission interview when the client attempts to shift the session focus to the nurse by asking personal questions. Which statement by the nurse is most appropriate?

"I have a family. Tell me about you and your family.

An adolescent client with depression and a suicide attempt is admitted to an inpatient unit. The nurse notes that the client describes a recent breakup of a dating relationship with an emotionless tone and a flat facial expression. What will the nurse do next?

Ask the client if there is a plan in place for suicide.

In a mental health interview, a client who has returned from military service reports feeling ashamed of being "weak" and of letting past experiences control thoughts and actions in the present. What is the nurse's best response?

Many people who've been in your situation experience similar emotions and behaviors."

A client states, "I feel so sad. I don't think I can go on anymore." Which is the most therapeutic response the nurse can offer the client?

You feel like you can't go on anymore?"

The nurse is teaching the family of a client with a psychiatric disorder about traditional antipsychotic drugs and their effect on symptoms. Which symptom would be most responsive to these types of drugs?

delusions Explanation: Positive symptoms such as delusions, hallucinations, thought disorder, and disorganized speech respond to traditional antipsychotic drugs. The other options belong in a category of negative symptoms, including affective flattening, restricted thought and speech, apathy, anhedonia, asociality, and attention impairment. Negative symptoms are more responsive to the new atypical antipsychotics, such as clozapine, risperidone, and olanzapine.

The nurse is evaluating the test results of a client undergoing testing for depression. Which results of from a dexamethasone suppression test (DST) would the nurse interpret as indicative of depression?

elevated afternoon serum cortisol

The school nurse is conducting health assessments for a group of children. Which of the following situations encountered by the nurse raises suspicion of child neglect?

A child reports of constant hunger. Explanation: Constant hunger is a possible indicator that a child is being neglected. The other options would all be considered relatively age appropriate behaviors rather than being indicative of a more serious situation.

A nurse notices that a depressed client who has been taking amitriptyline hydrochloride for 2 weeks has become very outgoing, cheerful, and talkative. The nurse suspects that the client:

may be experiencing increased energy and is at increased risk for suicid

An adolescent is a heavy user of marijuana and alcohol. When the nurse confronts the client about their drug and alcohol use, they admit previous heavy use in order to feel more comfortable around peers and achieve social acceptance. They acknowledge trying to stay clean since their parents found out and had them seek treatment. When the nurse develops a plan of care with the client, what should be the highest priority to help them maintain sobriety?

peer recognition that does not involve substance use

A young child who has been sexually abused has difficulty putting feelings into words. Which approach should the nurse employ with the child?

engaging in play therapy Explanation: The dolls and toys in a play therapy room are useful props to help the child remember situations and re-experience the feelings, acting out the experience with the toys rather than putting the feelings into words. Role-playing without props commonly is more difficult for a child. Although drawing itself can be therapeutic, having the abuser see the pictures is usually threatening to the child. Reporting abuse to authorities is mandatory but does not help the child express feelings.

The nurse assesses a client with depressive disorder for discharge readiness. Which behavior would lead the nurse to determine that the client is ready for discharge?

verbalization of feeling in control of self and situations

The client is Asian and non-English speaking. The nurse arranges for the interpreter who can speak the client's dialect and begins the health assessment. The client is describing symptoms as numbness, feeling "hot under the skin," and thinking too much. The nurse should next ask specific questions about which symptom?

Pain

The family of a client with a terminal illness tells the hospice nurse supervisor that they have lost hope for a peaceful death for their loved one. While talking to this family about their concerns, the nurse would immediately explore their concerns about which health care issue?

effective management of the client's physical discomfor

A couple seeks emergency crisis intervention because one client slapped the other client repeatedly the night before. The first client who inflicted the violence reports a childhood marred by an abusive relationship with a parent. To assess for the likelihood of further violence and abuse, the nurse should determine that the first client:

has learned violence as an acceptable behavior.

A client in a long-term nursing care facility who decides to be placed on hospice care expresses to the nurse, "I have outlived my family and friends; I have lost hope and there is no need for me to continue on." What underlying client concerns would the nurse first address with this client?

loneliness and feelings of isolation

A client admitted for investigation of a tumor asks the nurse, "Do you think I have cancer?" Which response by the nurse is most therapeutic?

You sound concerned about what the tests results might be." Explanation: This response allows the client to express the client's feelings and promotes further discussion. Referring the client to the healthcare provider ends the discussion and prevents exploration of the client's feelings. Generalizing about tumors shifts the focus from the client. The statement about the need for tests is true but doesn't focus on the client's feelings and concerns.

The nurse is working with a highly culturally diverse group of mostly young adult clients who have substance abuse issues. Many clients in the group have had difficult social circumstances and experience relapses. What would be the most appropriate nursing intervention in dealing with these clients?

Encourage motivation and confidence so that the clients can better deal with the triggers that cause them to repeat their behaviors. Clients with multiple episodic occurrences of relapse are unable to adapt to the stressors in their lives and need support with this. Fostering client confidence will help clients deal with the triggers that cause them to relapse.

The mental health unit provides a unit landline for clients to use for telephone calls. A client with bipolar disorder is monopolizing the use of the telephone by making several calls each day, interfering with the ability of other clients to use the telephone. What should the nurse do?

Limit the amount of calls the client can make each day. Explanation: The nurse should limit the amount of telephone calls the client can make. Setting limits for a client with bipolar disorder, mania, helps to control the hyperactive client who has excessive goal-directed activity, especially when it interferes with the rights of other clients. Giving the client access to his cell phone rewards the behavior. Reminding the client that others need to use the telephone will probably be futile because the client with mania is experiencing cognitive impairment and needs to be active. Taking away the client's telephone privileges is not the best action because the client has a right to use the telephone. The nurse is responsible for helping the client manage behavior by setting constructive limits.

A client was admitted to the behavioral health unit with a diagnosis of severe depression. The client was started on bupropion. Forty-eight hours after initiating the drug therapy, the client has recovered from depression, is laughing, singing, and dancing in the hallway and in the sitting room. How should the nurse interpret this behavior?

The client is most likely bipolar rather than depressed, and the healthcare provider should be notified of the behavior.

A partner of a client diagnosed with Kaposi's Sarcoma has refused antiretroviral therapy. The partner confides in the nurse that the client "has just given up. I know with medication my partner will get better and we can go back to the life we once had." The nurse identifies that the partner is experiencing which stage of grieving?

denial stage

A client with a diagnosis of major depression and a history of several suicide attempts tells a nurse, "I have no reason to live. Nobody cares about me." Which response by the nurse is mosttherapeutic?

"How long have you been feeling like this?"

After several months of taking olanzapine, the client reports that he is no longer hearing voices of any kind. Which statement would confirm that the client is developing insight into his illness?

"I didn't realize how sick I could get from a chemical brain imbalance." Explanation: Insight into the illness is demonstrated when the client recognizes the relationship between the chemical imbalance and his illness and symptoms. Stating that the olanzapine is the best medicine or that the client's mother is proud of him for staying on his medicines reflects awareness about the effect of medications and the need for compliance. Stating that he may be able to get a part-time job indicates an awareness of his increased capacity for work.

A client with a diagnosis of schizophrenia is admitted to the inpatient unit of the mental health center. The client starts shouting, "The government of France is trying to kill me!" Which response is most appropriate?

"I don't see evidence that a foreign government is trying to hurt you. You must feel frightened by this."

A nurse is caring for a 14-year-old adolescent who states, "No one understands me." Which statement by the nurse best demonstrates empathy?

"It's difficult to be a teenager. Tell me more about your experiences." Explanation: Empathy is the ability to put oneself in another's place and experience a feeling as that person is experiencing it. The correct answer acknowledges the adolescent's feelings and conveys an understanding without intimidating the client. Asking how adults can help and reflecting on parental understanding or favorite coursework is helpful overall but does not demonstrate empathy for the client.

A 40-year-old client with schizophrenia lives in a rooming house. The client scratches vigorously and reports creatures eating at the skin. Which intervention should be done first?

Assess the physical problems.

A nurse notices that a depressed client who has been taking amitriptyline hydrochloride for 2 weeks has become very outgoing, cheerful, and talkative. The nurse suspects that the client: You Selected:

may be experiencing increased energy and is at increased risk for suicide. Explanation: As antidepressants take effect, an individual suffering from depression may begin to feel energetic enough to mobilize a suicide plan. Amitriptyline is an antidepressant, not an antipsychotic. The client shouldn't be discharged until the risk of suicide has diminished. The client's elevated mood is a response to the antidepressant, not an indication of a split personality.

An 8-year-old client enters a healthcare facility. During assessment, the nurse discovers that the client is experiencing the anxiety of separation from the caregivers. The nurse makes the nursing diagnosis of fear related to separation from familiar environment and family. Which nursing intervention is likely to help the client cope with fear and separation? Select all that apply. Encourage caregivers to bring a favorite toy/stuffed animal from home for the client. Ask the physician to explain to the client why staying in the healthcare facility is needed. Tell the client they must act like a "big kid" while in the facility. Have the caregivers stay with the client and participate in the care. Maintain as many bedtime rituals as possible while the client remains in the facility.

Encourage caregivers to bring a favorite toy/stuffed animal from home for the client. Have the caregivers stay with the client and participate in the care. Maintain as many bedtime rituals as possible while the client remains in the facility.

A client is irritable and hostile. They become agitated and verbally lash out when their personal needs are not immediately met by the staff. When the client's request for a pass is refused by the health care provider, they utter a stream of profanities. Which statement best describes the client's behavior? The client's anger is:

not intended personally.

A visiting nurse provides episodic care at a childcare center for preschool children. Nursing Notes ​4/1 Called to childcare center to assist with Amy's care. Amy was fully potty trained for one year and is now refusing to use the toilet for bowel movements and frequently has urine accidents. Amy has been biting classmates and having episodes of anger in class. Amy's parents have decided to divorce; the teachers have spoken to each parent separately about Amy's behavior. The nurse has been asked to review and provide a plan of care in Amy's electronic health, developmental and educational records. Which does the nurse consider when planning the care for the client and parents?

Toddlers often react to stress with regression and aggression, warranting family therapy, and an organized plan of care.

A client with severe depression states, "My heart has stopped and my blood is black ash." The nurse interprets this statement to be evidence of which problem?

delusion Explanation: A client with severe depression may experience symptoms of psychosis such as hallucinations and delusions that are typically mood congruent. The statement, "My heart has stopped and my blood is black ash," is a mood-congruent somatic delusion. A delusion is a firm, false, fixed belief that is resistant to reason or fact. A hallucination is a false sensory perception unrelated to external stimuli. An illusion is a misinterpretation of a real sensory stimulus. Paranoia refers to suspiciousness of others and their actions.

A nurse is conducting a spiritual assessment on a client admitted for surgery and developing a plan of care based on this assessment. To help ensure that the nurse is most successful in meeting the client's spiritual needs and promote a comfortable working relationship with the client, which aspect would be most important initially for the nurse?

developing an awareness of one's own beliefs about the connection between spirituality and health

The nurse is helping a client deal with personal issues and painful feelings. What does the nurse identify as a crucial goal of therapeutic communication?

conveying client respect and acceptance even if not all of the client's behaviors are tolerated

The nurse develops the preoperative teaching plan for a 14-month-old child with an undescended testis who is scheduled to have surgery. Which method is most appropriate?

Explain to the parents how the defect will be corrected. Explanation: Preoperative teaching would be directed at the parents because the child is too young to understand the teaching. Telling the child that their penis and scrotum will be "fixed," telling the child they will not see incisions after surgery, and using a doll to illustrate the surgery are appropriate interventions for a preschool-age child.

A school-age client with a spinal cord injury is moved to the rehabilitation unit. The nurse notes that the child tends to refuse to cooperate in care and to be hostile. The nurse interprets this behavior as indicative of which response?

a stage of grief reaction Explanation: After a catastrophic injury, individuals commonly experience grief. Initially, the person experiences denial, the most common response. With gradual awareness of the situation, anger commonly occurs. The child is demonstrating anger, not rebellion, as they gradually become aware of their situation. Rebellion is the child's way to maintain autonomy and individuality. It is a reaction to rigid rules. Examples include refusing to follow a treatment protocol when the child had no input and running away. Sensory overload would cause the child to be irritable and tired and to have difficulty sleeping. Too much attention usually would lead to irritability, difficulty sleeping, and

Despite the presence of a large cohort of elderly residents of Asian heritage, a long-term care facility has not integrated the Asian concepts of hot and cold into meal planning. The nurses at the facility should recognize this as an example of what?

cultural blindness

A client who is suspicious of others, including staff, is brought to the hospital wearing a wrinkled dress with stains on the front. The assessment also reveals a flat affect, confusion, and slow movements. Which goal should the nurse identify as the initial priority when planning this client's care?

helping the client feel safe and accepted Explanation: The initial priority for this client is to help them overcome their suspiciousness of others, including staff, and thereby feel safe and accepted. Introducing the client to others, giving the client information about the program, and providing clean clothes are important, but these are of lower priority than helping the client feel safe and accepted.

A nurse is teaching a client stress management. Which techniques would be considered adaptive coping skills? Select all that apply. maintain control of my life set realistic goals for each day practice relaxation techniques balance sleep, rest, and exercise try to eliminate total anxiety

set realistic goals for each day practice relaxation techniques balance sleep, rest, and exercise

The nurse answers a call on a telephone hotline from a client who was at the crisis center once in the past when they made a suicide threat. The client says, "Don't try to help me anymore. This is it. I've had enough, and I have a gun in front of me now." Then the client hangs up the telephone. Which call should the nurse make first?

police, to request their intervention Explanation: The nurse's first responsibility when a client threatens suicide is to do whatever can be done most quickly to protect the client from themself. When the nurse is in a crisis center and the client is at home, it is best to call the police to intervene. They will be able to reach the client quickly and are experienced in handling such situations. It is appropriate to err on the side of safety rather than to assume that the client is not serious about a suicide threat.Attempting to call the client first would be a serious error in judgment because the client has a lethal means, a gun, readily available and is in immediate danger of killing themself.Asking the client's spouse or neighbor to intervene is inappropriate because it may cause either person to be hurt, especially since the client has a weapon.

A client begins to experience alcoholic hallucinosis. After administering medication, what is the best nursing intervention?

providing a quiet environment Explanation: Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment to reduce stimulation and administering ordered central nervous system depressants in dosages that control symptoms without causing oversedation. Although bed rest is indicated, restraints are unnecessary unless the client poses a danger to self or others. Also, restraints may increase agitation and make the client feel trapped and helpless when hallucinating. Offering oral liquids every 30 minutes and measuring blood pressure every 15 minutes would interrupt the client's rest. To avoid overstimulating the client, the nurse should check the client's blood pressure and offer liquids every 2 hours.