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","C","E"]
Explanation
Choice A rationale: Disrupted sleep is a common symptom of postpartum depression, and clients may experience difficulty falling asleep or staying asleep.
Choice B rationale: Grandiosity is more indicative of bipolar disorder (mania) rather than postpartum depression.
Choice C rationale: Poor concentration is a common cognitive symptom associated with postpartum depression.
Choice D rationale: Compulsive behavior is not typically associated with postpartum depression.
Choice E rationale: Sadness is a hallmark symptom of depression, including postpartum depression.
Correct Answer is A
Explanation
Choice A rationale: Documenting the finding on the Abnormal Involuntary Movement Scale (AIMS) is appropriate. The AIMS is a standardized tool used to assess and document abnormal movements associated with antipsychotic medications, such as tardive dyskinesia.
Choice B rationale: Assisting the client in recognizing her manifestations of anxiety is unrelated to the observed foot tapping and does not address the potential side effects of antipsychotic medication.
Choice C rationale: Preparing to initiate seizure precautions for the client's safety is not indicated based on the observed foot tapping. Seizure precautions are not typically associated with antipsychotic medication side effects.
Choice D rationale: Advising the client that she has developed tolerance to the medication is speculative and not supported by the information provided. The observed foot tapping may be indicative of extrapyramidal side effects rather than tolerance.
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