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?

Recommend that the client talk with a social worker today.

Offer the client a safe place to relax before the Interview.

Assure client of an interview with the healthcare provider today.

Ask the client to describe the stalker and If It is frequent.

Answer and Explanation

The Correct Answer is B

Choice A Rationale: While talking to a social worker could be beneficial, it may not address the client's immediate need for safety and comfort. Social work intervention is important, but the priority is to ensure the client feels secure in the current environment.
Choice B Rationale: Offering a safe place to relax is crucial as it addresses the client's immediate need for safety and security. Feeling safe can help reduce anxiety and allows the client to compose themselves before discussing their concerns in detail.
Choice C Rationale: Assuring an interview with the healthcare provider is important, but it does not prioritize the client's immediate emotional and psychological needs. The assurance of care is part of the overall treatment plan but is secondary to providing a safe environment.
Choice D Rationale: Asking the client to describe the stalker is part of the assessment process, but it is not the most important initial action. The client's immediate emotional state must be stabilized before any detailed information gathering can be effective.

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Correct Answer is B

Explanation

Choice A rationale: Demonstrates thought-blocking is incorrect. Thought-blocking involves a sudden interruption in the client's speech, whereas the client in this scenario is experiencing racing thoughts.

Choice B rationale: Exhibits tangential thinking is the correct description. Tangential thinking involves presenting numerous ideas that are loosely or not at all connected. The client's statements reflect tangential thinking as she jumps from one idea to another without clear connections.

Choice C rationale: Displays the use of word salad is incorrect. Word salad refers to a mix of words and phrases that lack coherence and do not form a meaningful statement. The client's statements, though rapid, are connected and form a series of thoughts. Choice D rationale: Uses incoherent speech is incorrect. Incoherent speech implies a lack of clarity and organization in the client's verbal expression. The client's statements, while fast-paced, maintain coherence and are comprehensible.

A. Body mass index of 21. B. Blood pressure of 110/70 mm Hg. C. Potassium level of 2.9 mEq/dl (2.9 mmol/L). D. WBC of 10,000/mm3 (10 x 109/L).

Correct Answer is C

Explanation

Choice A rationale: A body mass index (BMI) of 21 is within the normal range and does not require immediate notification to the healthcare provider.

Choice B rationale: A blood pressure of 110/70 mm Hg is within the normal range for an adolescent and does not require immediate notification.

Choice C rationale: A potassium level of 2.9 mEq/dL (2.9 mmol/L) is below the normal range (hypokalemia) and requires notification to the healthcare provider due to the potential for adverse effects on cardiac and neuromuscular function.

Choice D rationale: A WBC of 10,000/mm3 (10 x 109/L) falls within the normal range and does not require immediate notification.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is C

Explanation

The nurse is providing care for a client diagnosed with a borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the nurse use when changing this client's dressings?

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