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 D
Explanation
A. Informing the client about confidentiality rights typically occurs during the orientation phase of the therapeutic relationship, not the working phase.
B. Establishing boundaries between the nurse and the client is an ongoing process that occurs throughout the therapeutic relationship, not just during the working phase.
C. Setting short- and long-term objectives for the future typically occurs during the orientation phase and continues throughout the therapeutic relationship, not just during the working phase.
D. During the working phase of the therapeutic relationship, the nurse and client collaborate to achieve the goals identified during the orientation phase. The nurse evaluates the client's progress toward these goals and adjusts interventions as necessary to promote therapeutic outcomes.
Correct Answer is A
Explanation
A. Generalizing involves making broad statements that apply universally, without specific evidence or context. The client's statement, "My partner is always criticizing me," is a generalization because it suggests a pervasive pattern of behavior without specifying particular instances or situations.
B. Manipulating involves influencing or controlling others for personal gain. The client's statement does not demonstrate manipulation.
C. Distracting involves diverting attention away from the topic at hand. The client's statement is not an example of distraction.
D. Placating involves seeking to please others or avoid conflict by agreeing with them. The client's statement does not demonstrate placating behavior.
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