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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While ineffective coping related to inadequate stress management is a valid nursing diagnosis, it is not the highest priority in this scenario. The client’s threat to commit suicide with a handgun indicates a clear and immediate risk.
Choice B rationale
Hopelessness related to recent divorce is a significant concern and may contribute to the client’s suicidal ideation. However, the immediate threat of suicide takes precedence.
Choice C rationale
Spiritual distress related to conflicting thoughts about suicide and sin may be a factor in the client’s mental state, but it is not the immediate concern. The client’s life is in danger, which must be addressed first.
Choice D rationale
Risk for suicide related to a highly lethal plan is the highest priority nursing diagnosis. The client has a clear plan (using a handgun) and means (access to a handgun), indicating a high risk for suicide.
Correct Answer is A
Explanation
The correct answer is Choice A.
When communicating with an angry patient, the nurse must first listen actively. Active listening allows the nurse to identify the key issues and work through them methodically.
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