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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Waiting for the client to respond allows for a patient-centered approach, respecting the client's pace and giving them the opportunity to express themselves when ready.
Choice B rationale: Assuming the client's ability to hear the question may be accurate, but the client's nonverbal cues suggest a need for patience and a non-coercive approach.
Choice C rationale: Changing the question may not address the client's current feelings and might disrupt the therapeutic process.
Choice D rationale: Returning at a later time might be appropriate if the client continues to be unresponsive, but it is not the initial action in this situation.
Correct Answer is C
Explanation
Choice A rationale: Self-control is not the primary issue identified in this scenario. The client's self-blame may be related to other factors.
Choice B rationale: Self-actualization is not the primary issue in this scenario. The client is dealing with feelings of self-blame and potential guilt.
Choice C rationale: Self-esteem is the most relevant issue in this scenario. The client expresses feelings of self-blame, indicating a potential impact on self-esteem. Addressing self-esteem is crucial for the client's emotional well-being.
Choice D rationale: Self-absorption is not the primary issue in this scenario. The client's focus on self-blame and guilt is related to self-esteem concerns.
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