A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

Compromised family coping.

Ineffective sexual patterns.

Impaired environmental interpretation.

Disturbed sensory perception.

Answer and Explanation

The Correct Answer is D

Choice A rationale:
Compromised family coping may be a concern, but it is not the most immediate priority given the client's symptoms of altered reality.

Choice B rationale:
Ineffective sexual patterns is not the primary concern in this scenario, as the client's delusional beliefs and hallucinations take precedence.

Choice C rationale:
Impaired environmental interpretation may be relevant, but it is not the most immediate priority compared to addressing the client's altered perception of reality.

Choice D rationale:
The client's delusional beliefs and hallucinatory experiences suggest disturbed sensory perception, which is a priority nursing problem that requires immediate attention and intervention. These symptoms may indicate a serious mental health condition, such as psychosis, that necessitates psychiatric evaluation and care.

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Correct Answer is C

Explanation

Choice A rationale:
Using an incentive spirometer is not directly related to the post-TUNA discharge instructions for a client with BPH. Incentive spirometry is typically used to improve lung function and prevent respiratory complications.

Choice B rationale:
Monitoring the urinary stream for a decrease in output may be important, but it is a general instruction that may not be specific to the TUNA procedure. The primary focus after TUNA is often on monitoring for complications related to the procedure.

Choice C rationale:
Reporting when hematuria (blood in the urine) becomes pink-tinged is important. While some degree of hematuria is expected after TUNA, a change in color to pink or any other concerning changes should be reported to the healthcare provider as it could indicate complications.

Choice D rationale:
There is typically no need to restrict physical activities after a TUNA procedure. In fact, healthcare providers often encourage patients to resume normal activities gradually unless otherwise instructed due to specific complications.

A. Assist the client with relaxation techniques in the group. B. Escort the client from the group to reduce stimuli. C. Provide education about ways to cope with anxiety. D. Ask the client to describe and identify the source of the feelings.

Correct Answer is A

Explanation

Choice A rationale:
Assisting the client with relaxation techniques within the group is an appropriate and immediate intervention for managing severe anxiety. This approach can help the client regulate their anxiety levels and provide a sense of support in the therapeutic environment.

Choice B rationale:
Escorting the client from the group to reduce stimuli may be considered if the client's anxiety becomes overwhelming and they cannot manage it within the group setting. However, it is generally preferable to try in-group interventions first.

Choice C rationale:
Providing education about ways to cope with anxiety is valuable, but it may not be the most effective intervention in the moment when the client is already experiencing severe anxiety. Practical techniques should be initiated first.

Choice D rationale:
Asking the client to describe and identify the source of the feelings may be a useful therapeutic technique in individual therapy sessions but may not be the best immediate intervention during a group therapy session when the focus is on managing acute anxiety.

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A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

Correct Answer is C

Explanation

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

Correct Answer is A

Explanation

The nurse is developing a plan of care for an older client with hypertension who reports chest pain on exertion. Which outcome should the nurse include in the plan of care for this client?

The nurse plans to use role-playing as a therapeutic measure. Which individual is most likely to benefit from this type of therapeutic intervention?

A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first?

Patient Data Exhibits here The nurse is reviewing the physician's orders. Which of the following physician's orders requires priority attention from the nurse? Select all that apply.

Patient Data Exhibits The nurse determines the plan of care. For each action, click to indicate whether they would be included or not included in the plan of care for the client. Each row must have only one response option selected. Actions