A nurse in a mental health facility is caring for a group of clients. After assessing the clients, which of the following clients requires an update to their plan of care to ensure client safety?
A client who has anorexia nervosa and expresses a fear of gaining weight
A client who has bipolar disorder and is exhibiting poor impulse control
A client who has schizophrenia and is exhibiting clang associations in their speech
A client who has Alzheimer's disease and is having difficulty remember names of family members
The Correct Answer is B
A. While a client with anorexia nervosa may require close monitoring and support, expressing a fear of gaining weight does not necessarily indicate an immediate safety concern that requires an update to the plan of care.
B. Bipolar disorder can involve manic episodes characterized by impulsivity and risk-taking behaviors. Exhibiting poor impulse control indicates a potential safety concern that requires an update to the plan of care to ensure the client's safety and the safety of others.
C. Clang associations in speech are a symptom of disorganized thinking commonly seen in schizophrenia. While it may indicate a need for intervention, it does not necessarily require an immediate update to the plan of care for safety reasons.
D. Difficulty remembering names of family members is a symptom of Alzheimer's disease and may require ongoing support and management but does not present an immediate safety concern that requires an update to the plan of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Discussing the provider's goals for the client's care may be helpful but does not directly address the client's reported non-adherence or potential barriers to medication compliance.
B. Asking the client if the medication is causing adverse effects allows the nurse to assess for potential reasons why the client is not taking the medication regularly, such as side effects or discomfort, and address those concerns.
C. Requesting a second antipsychotic medication without addressing the client's reasons for non- adherence may not effectively improve medication compliance and could increase the risk of adverse effects or drug interactions.
D. Threatening the client with admission to an inpatient care facility is coercive and may not address the underlying reasons for non-adherence, potentially worsening the therapeutic
relationship and trust.
Correct Answer is C
Explanation
A. Changing the subject when the client becomes upset may invalidate their feelings and hinder emotional expression and processing.
B. Discouraging the client from forming new relationships may deprive the client of potentially meaningful connections during their remaining time.
C. Allowing the client unlimited time for the grieving process acknowledges the client's emotional response to their diagnosis and respects their individual needs and coping mechanisms.
D. Offering advice about treatment choices may be appropriate in some situations but should be done in collaboration with the client's healthcare team and in consideration of their wishes and values.
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