A charge nurse on a mental health unit is receiving a change of shift report for a group of clients.
Complete the following sentence by using the lists of options.
The nurse should first collect data from
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}
Client 1 (First Priority):
- Experiencing command hallucinations: Command hallucinations are auditory hallucinations that instruct the client to harm themselves or others, posing an immediate safety concern.
- Potential risk of self-harm: Persecutory delusions and statements indicating "the agents are watching" suggest escalating paranoia, increasing the risk of dangerous behaviors or impulsive self-protective actions. Immediate intervention is essential to prevent harm.
Client 2 (Lower Priority):
- Stopped taking medication: Non-compliance with medication has led to severe depressive symptoms, including isolation, withdrawal, and psychomotor retardation.
- Becoming isolated and withdrawn: While concerning, the risk is lower than active command hallucinations, making this a lower priority for immediate assessment. However, this client requires evaluation soon after Client 1.
Client 3 (Lowest Priority):
- Low lithium level (0.7 mEq/L): This level is slightly below the therapeutic range (0.8 to 1.2 mEq/L) but not critically dangerous.
- Increased risk of agitation and instability: The symptoms of agitation and poor sleep are concerning, but immediate safety threats are less imminent compared to command hallucinations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
A. Client 5 (Streptococcal pharyngitis): Proper isolation and precautions were implemented, including a private room and surgical mask during transport. No follow-up is needed.
B. Client 4 (Mycobacterium tuberculosis): Requires follow-up. Tuberculosis requires a negative pressure room, not a positive airflow room. Positive airflow rooms are used for clients who need protection from outside pathogens, such as those who are immunocompromised.
C. Client 3 (Herpes simplex): Correct precautions were implemented. Herpes simplex (when involving open lesions) requires contact precautions, including gown and gloves. No follow-up is necessary.
D. Client 2 (Clostridium difficile): Appropriate precautions were taken, including a private room and the use of gown and gloves for direct care. No follow-up is needed.
E. Client 1 (Pertussis): Requires follow-up. Pertussis is transmitted via respiratory droplets, but placing the client in a negative pressure room is unnecessary. Droplet precautions (standard private room and surgical mask use within 3 feet) are sufficient. Negative pressure rooms are reserved for airborne infections such as tuberculosis.
Correct Answer is C
Explanation
A. Applying the restraint over the client's gown: Restraints should be applied over clothing or a gown to prevent skin irritation and ensure comfort.
B. Using a quick-release knot to secure the restraint: A quick-release knot is the recommended method for securing restraints to ensure they can be removed quickly in an emergency.
C. Placing the restraint across the client's chest: Belt restraints should be placed around the waist, not the chest, as chest placement can impair breathing.
D. Tying the restraint to the bed frame: Restraints should be tied to the bed frame (not the side rails) to prevent injury during bed movement.
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