A homeless male who was found sitting in the middle of a busy street is brought to the emergency department (ED). On admission, the client is confused and has difficulty answering questions. After ruling out a physiological etiology for the client's behavior, he is transferred to the mental health unit. When admitting the client to the unit, which action is most important for the nurse to take?

Ask the client about his recent substance use.

Perform a mental status exam.

Assess the client from head-to-toe.

Determine the number of previous hospitalizations.

Answer and Explanation

The Correct Answer is B

Choice A rationale: Asking the client about recent substance use is essential in assessing potential intoxication or withdrawal, which could contribute to the client's confused state. However, performing a mental status exam is the most important action to take.

Choice B rationale: The most important action for the nurse to take is to perform a mental status exam. This will help the nurse to assess the client's level of consciousness, orientation, memory, attention, mood, affect, thought process, and judgment. The mental status exam will also help the nurse to identify any signs of psychosis, delirium, dementia, or other mental disorders that may explain the client's behavior. Choice C rationale: Assessing the client from head-to-toe is a general nursing action but does not address the immediate need related to potential substance use. Choice D rationale: Determining the number of previous hospitalizations is relevant but does not address the current concern of substance use contributing to confusion.

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Correct Answer is B

Explanation

Choice A rationale: Asking about a bad experience may provide additional information, but it does not directly address the behavioral aspect of obsessive-compulsive disorder (OCD).

Choice B rationale: This response shows empathy and curiosity and invites the client to explore their cognitive processes behind their compulsive behavior. The nurse can help the client identify and challenge their irrational or distorted thoughts that fuel their anxiety and drive them to check the locks repeatedly.

Choice C rationale: Acknowledging that repeating the same behavior helps diminish anxiety might reinforce the client's belief that checking the locks is necessary and beneficial, which could prevent them from seeking alternative coping strategies.

Choice D rationale: Stating that feelings of being driven are related to anxiety is a general observation and may not contribute to a deeper understanding of the client's experience with OCD.

A. Monitor the client carefully for binging activities. B. Assess and report the client's electrolyte status to the healthcare provider. C. Assign the client's care to a nurse of approximately the same age. D. Schedule the client for group therapy with other bulimic clients.

Correct Answer is B

Explanation

Choice A rationale: Monitoring for binging activities is important, but addressing the potential physiological complications of bulimia, such as electrolyte imbalances, takes precedence.

Choice B rationale: Assessing and reporting the client's electrolyte status is the highest priority as bulimia nervosa can lead to severe electrolyte imbalances, which may result in life-threatening complications.

Choice C rationale: Assigning care based on age is not a priority in addressing the immediate health risks associated with bulimia nervosa.

Choice D rationale: While group therapy is beneficial, addressing the client's physical health and safety is the highest priority.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with obsessive compulsive disorder (OCD) reports feeling "driven" to check the locks on the front door at least six times every night. Which response is best for the nurse to provide?

Correct Answer is B

Explanation

A young adult client is admitted to a psychiatric facility with a diagnosis of bulimia nervosa. Which nursing intervention has the highest priority?

Correct Answer is B

Explanation

Which goal has the highest priority for an adolescent client who is hospitalized for weight loss related to anorexia nervosa?

A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent when the client says, "I don't know how I will go on." What is the reason for the nurse's behavior?

Which client Information indicates the need for the nurse to use the CAGE questionnaire during the admission interview?

A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client's rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?

A client with chronic alcoholism receives a prescription for disulfiram. Which client statement indicates that this medication teaching has been effective?

The nurse is providing teaching to a client and family about schizophrenia before discharge from an inpatient facility. The nurse should instruct the family to notify the healthcare provider when which behavior is observed?

After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy. Which action should the nurse implement?

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?