A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determine the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?

Ineffective community coping.

B Disturbed sensory perception.

Self-care deficit.

Acute confusion.

Answer and Explanation

The Correct Answer is D

A.   Ineffective community coping may be a concern for a homeless individual but is not the priority in this scenario where the client is disoriented and confused.
B.   Disturbed sensory perception typically involves alterations in visual, auditory, tactile, or olfactory senses, which may not be the primary issue in this case.
C.   While self-care deficit could be a concern for a homeless individual, it is not the priority when the client is disoriented, disorganized, and confused.
D.   Acute confusion is the priority problem because the client is disoriented, disorganized, and confused, indicating a cognitive impairment that needs immediate attention. E. There is no specific rationale provided for this option.

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Correct Answer is D

Explanation

Rationale for A: The phrase "Client claims" may imply doubt or a lack of belief in the client's account. It's important to use non-judgmental language that reflects the client's words without interpretation or bias. This choice is less appropriate because it doesn't use the client's exact words.

Rationale for B: This statement generalizes the situation and lacks the specificity of the client’s actual words. It may not capture the emotional impact or the client's clear identification of the event as rape. Direct quotations are preferred for documenting sensitive situations like this.

Rationale for C: While "Client has been sexually assaulted" is accurate, it is a general term. It is preferable to document the client's own words verbatim in the medical record to ensure clarity and to avoid any misinterpretation or assumptions.

Rationale for D: Documenting the client's exact words ("My date raped me tonight") ensures that the medical record accurately reflects the client's experience without interpretation. It is crucial to use the client's own language when documenting incidents of sexual assault.

A. A The client should plan to participate in group or individual therapy while at college. B. The client's serum lithium levels should be routinely evaluated. C. The client should be aware of the signs and symptoms of his illness. D. Despite the illness, the client should be able to live away from home.

Correct Answer is B

Explanation

A. While participation in therapy may be beneficial, the most important consideration with lithium therapy is monitoring serum levels to ensure therapeutic efficacy and avoid toxicity.
B. Lithium therapy requires regular monitoring of serum levels to maintain therapeutic efficacy and prevent toxicity, especially during times of transition or stress such as starting college
C. While it is important for the client to be aware of the signs and symptoms of his illness, routine monitoring of serum lithium levels is more crucial for maintaining stability while living away from home.
D. While independence is a positive goal, the focus in this scenario should be on ensuring the client's safety and stability through appropriate monitoring of lithium levels.

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A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determine the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A young female client is admitted to the emergency room because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record as the client's chief complaint?

Correct Answer is D

Explanation

A male client with a recent diagnosis of bipolar disorder takes lithium carbonate daily. The client informed the school nurse of the desire to live away from home to attend college after graduating in one month. Which information is most important for the nurse to provide the client and his family?

Correct Answer is B

Explanation

The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?

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The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

A client with a history of alcoholism is admitted for detoxification. Based on treatment protocol, the nurse gives the client a dose of lorazepam 6 mg. Which additional prescription should the nurse administer immediately?

Which individual should the nurse consider at highest risk for suicide?

An adult female client is brought to the Emergency Center after fainting at work. The nurse completes an assessment of the client and identifies caregiver role strain as a nursing problem. Which information best supports this problem?

The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

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