A 60-year-old individual strays from a football game during halftime and is discovered 48 hours later, sleeping on a park bench 100 miles away.
The individual is brought to the emergency department by the police.
The individual can state their name and address but has no memory of the past 2 days. What is the priority nursing action?
Monitor mental status.
Encourage the individual to recall recent events.
Assess vital signs.
Contact family members.
The Correct Answer is C
Choice A rationale
Monitoring mental status is important, but it is not the priority nursing action in this situation. The individual has been found after being missing for 48 hours and the immediate concern should be their physical well-being.
Choice B rationale
Encouraging the individual to recall recent events may be part of the assessment process, but it is not the priority nursing action. The individual’s physical health could be at risk after being outside for an extended period, and this should be addressed first.
Choice C rationale
Assessing vital signs is the priority nursing action. The individual has been found after being missing for 48 hours, potentially exposed to harsh weather conditions and without access to food or water. It is crucial to assess their physical state as they may be dehydrated, hypothermic, or have other immediate health concerns.
Choice D rationale
Contacting family members is important for providing information and support, but it is not the priority nursing action. The first concern should be to assess and stabilize the individual’s physical condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Negative symptoms of psychosis include anergia (lack of energy), flat affect (reduced emotional expression), and anhedonia (inability to feel pleasure)12131415.
Choice B rationale
Delusions are considered a positive symptom of psychosis, not a negative symptom.
Choice C rationale
Hallucinations are also considered a positive symptom of psychosis, not a negative symptom.
Choice D rationale
Anhedonia is indeed a negative symptom of psychosis, but it is not the only one.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Reviewing diagnostic test results is a crucial method for gathering data during the assessment phase of the nursing process. These results can provide valuable insights into the client’s health status and help to guide the planning and implementation of care.
Choice B rationale
Interviewing the client and significant others is another important method for data collection. This can help to gather information about the client’s symptoms, lifestyle, and personal history, which can all inform the care provided.
Choice C rationale
Performing a physical assessment is a key part of data collection in the nursing process. This involves examining the client’s physical condition and looking for any signs of illness or injury.
Choice D rationale
Interpreting the behaviors of the client is also a crucial part of data collection. This can provide insights into the client’s mental and emotional state, which can be particularly important in mental health nursing.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.