A client that is homeless, well-educated, and has chronic schizophrenia is admitted to the mental health unit when found by the police walking in the middle of the street. The client presents with a strong body odor, dirty clothes, and avolition. After a week of neuroleptic drug therapy, the client discusses with the nurse thoughts about bathing. Which statement suggests that the client is progressing?

I know that bathing helps prevent infectious diseases.

Others say I am dirty and smell badly, so I will bathe.

I will take a bath today as requested.

I feel good when I take care of myself.

Answer and Explanation

The Correct Answer is D

Choice A rationale: "I know that bathing helps prevent infectious diseases" is a factual statement but may not necessarily reflect progress in the client's overall functioning and engagement in self-care. It focuses on the practical aspect of bathing rather than the client's motivation and insight.

Choice B rationale: "Others say I am dirty and smell badly, so I will bathe" suggests an external motivation rather than intrinsic motivation. Progress is better indicated when the client expresses a personal desire to engage in self-care activities.

Choice C rationale: "I will take a bath today as requested" indicates compliance with external requests rather than an internal desire to care for oneself. It is essential to foster the client's intrinsic motivation for self-care.

Choice D rationale: "I feel good when I take care of myself" reflects an internal motivation and positive reinforcement associated with self-care. This statement suggests progress in the client's willingness to engage in personal hygiene activities.

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Correct Answer is ["A","C","D"]

Explanation

Choice A rationale: Giving concise and firm directions for hygiene and dressing helps provide structure and support during periods of manic behavior.

Choice B rationale: Engaging the client in competitive activities may exacerbate manic symptoms, so it is not the best approach.

Choice C rationale: Assigning the client to a single room provides a quieter and less stimulating environment, promoting a more controlled and therapeutic setting. Choice D rationale: Inviting the client for a walk when their energy is high allows for a structured outlet for excess energy and may help with symptom management.

Choice E rationale: Providing television programs with suspense may contribute to overstimulation and is not the best approach during manic episodes.

A. Ineffective breathing pattern. B. Risk for injury. C. Ineffective coping. D. Impaired comfort.

Correct Answer is A

Explanation

Choice A rationale: Ineffective breathing pattern is the highest priority nursing problem. Aspiration of a caustic material can lead to respiratory compromise, and ensuring adequate oxygenation takes precedence.

Choice B rationale: Risk for injury is important, but respiratory concerns associated with aspiration take priority in this situation.

Choice C rationale: Ineffective coping is relevant but does not take precedence over addressing immediate physiological needs such as breathing.

Choice D rationale: Impaired comfort is important, but the priority is to ensure the client's respiratory status and address potential complications of caustic material aspiration.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning the care for a client who is hospitalized with a bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?

Correct Answer is A

Explanation

The healthcare provider prescribes lithium carbonate for a client diagnosed with bipolar, manic depression. It is most important for the nurse to review which laboratory finding prior to beginning the drug therapy?

A client admitted to the mental health unit starts to shout and scream at the nurse. Which approach is best for the nurse to take?

A client is admitted to the emergency department because of a possible overdose of methadone and benzodiazepines. The admission respiratory rate is 6 breaths/minute. Based on this finding, the nurse should prepare for which intervention?

The nurse is preparing a client for discharge after treatment for cocaine abuse. The client is taking home a prescription for a new medication to control cocaine cravings. Which intervention is most important for the nurse to implement?

A client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because of a stalker. Which action is most important for the nurse to take?

The nurse interacts with a client who is very depressed and slow to respond to questions. The nurse asks the client to describe current feelings, but the client looks down at the table. Which action is best for the nurse to implement?

A client who experiences memory loss is diagnosed with Wernicke encephalopathy caused by alcohol addiction. Which intervention is most important for the nurse to implement?