A client diagnosed with major neurocognitive disorder is exhibiting behavioral problems daily. At change of shift, the client's behavior escalates from pacing to screaming and waving their arms while on the ground. Which action should be a nursing priority?

Anticipate the behavior and restrain when pacing begins.

Assess environmental triggers and potential unmet needs.

Assess for potential injury.

Consult the psychologist regarding behavior modification techniques.

Answer and Explanation

The Correct Answer is B

a. Anticipate the behavior and restrain when pacing begins: Restraint should be a last resort. Pacing might not necessarily lead to screaming, and early intervention should focus on de-escalation techniques.
b. Assess environmental triggers and potential unmet needs. De-escalation strategies should prioritize understanding why the client's behavior is escalating. Identifying environmental triggers or unmet needs (like pain, hunger, thirst) can help prevent further agitation.
c. Assess for potential injury: While assessing for injury is important, it should come after ensuring the safety of both the client and the staff by addressing the cause of the outburst.
d. Consult the psychologist regarding behavior modification techniques: Consultation is valuable, but immediate intervention to de-escalate the situation and understand the cause is the priority.

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Correct Answer is B

Explanation

a. Altered thought processes; call an emergency treatment team meeting. While altered thought processes are present, the urgent concern is the command hallucination directing the client to harm the psychiatrist. An emergency treatment team meeting may not provide the immediate intervention required.
b. Command hallucinations; warn the psychiatrist. This is correct because the client is experiencing command hallucinations that pose a direct threat to the psychiatrist. The nurse has a duty to warn the potential victim and ensure the safety of both the client and others.
c. Persecutory delusions; orient the client to reality. Persecutory delusions are present, but the immediate danger from the command hallucinations takes precedence. Orienting the client to reality does not address the urgent safety issue.
d. Magical thinking; administer an antipsychotic medication. Magical thinking is not the correct symptom here. Administering medication is part of treatment but does not address the immediate safety concern.

A. Clinically significant distress in occupational functioning. B. Sudden unexpected travel or confused wandering. C. An inability to recall their parent's contact information. D. Occasional periods of forgetfulness

Correct Answer is B

Explanation

a. Clinically significant distress in occupational functioning. While distress in occupational functioning may occur, it is not specific to dissociative fugue and is more broadly associated with various mental health disorders.
b. Sudden unexpected travel or confused wandering. This choice is correct because dissociative fugue is characterized by sudden, unexpected travel away from one's home or usual place of work, with an inability to recall some or all of one's past.
c. An inability to recall their parent's contact information. While memory loss is part of dissociative fugue, the focus is on broader, more significant amnesia than just inability to recall specific information like contact details.
d. Occasional periods of forgetfulness. This does not capture the severity or the specific nature of the amnesia involved in dissociative fugue.

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A client diagnosed with major neurocognitive disorder is exhibiting behavioral problems daily. At change of shift, the client's behavior escalates from pacing to screaming and waving their arms while on the ground. Which action should be a nursing priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with schizophrenia disorder states, "My psychiatrist is out to get me. I'm sad that the voice is telling me to stop the psychiatrist." What symptom is the client exhibiting, and what is the nurse's legal responsibility related to this symptom?

Correct Answer is B

Explanation

The nurse is providing care for a client diagnosed with dissociative fugue. Which behaviors would the nurse expect to see with this client?

Correct Answer is B

Explanation

The nurse understands that whether or not a client experiences crisis as a result of a stressful situation depends on the: (SELECT ALL THAT APPLY)

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