22.  The nurse discovers a client’s suicide note that details the time, place, and means to commit suicide. Which would be the priority nursing intervention and the rationale for this action?

25.  A victim of intimate partner violence comes to the crisis center seeking help. The nurse uses crisis intervention strategies that focus on what?

43.  A staff nurse tells another nurse, “I evaluated a new client using the modified SAD PERSONS scale and got a score of 10. I’m wondering if I should send the client home.” Select the best reply by the second nurse.

3.  A nurse is assessing a 6-year-old child who has experienced violence at school. Which of the following strategies should the nurse use during their assessment of this client?

14.  A client with schizophrenia spectrum disorder presents with bizarre behaviors and delusions. Which nursing action should be prioritized to maintain this client’s safety?

5.  A client experiencing severe anxiety suddenly begins running and shouting, “I’m going to explode!” The nurse should implement which intervention to best maximize the client’s safety?  

18.  A client comes to a psychiatric clinic experiencing sudden extreme fatigue, decreased sleep, and decreased appetite. The client works 12 hours a day and rates anxiety as 8/10 on a numeric scale. Which long-term outcome is realistic in addressing this client’s crisis?

34.  An older adult, diagnosed with Alzheimer’s disease, lives with family and has multiple bruises. The home health nurse talks with the older adult’s daughter, who becomes defensive and says, “My mother often wanders at night. Last night she fell down the stairs.” Which nursing diagnosis has priority?

A client experiencing moderate anxiety says, “I feel undone.” An appropriate response for the nurse should be:

2. A nurse is caring for an adolescent who has experienced abuse and neglect since early childhood. The nurse should understand that this is an example of which of the following types of trauma?