A nurse in an acute mental health care facility is prioritizing care for multiple clients.
Which of the following clients should the nurse see first?
A client who has obsessive-compulsive disorder and is upset about a change in daily routine.
A client who is taking clozapine to treat schizophrenia and reports a sore throat.
A client who has narcissistic personality disorder and is mocking others during group therapy.
A client who has depressive disorder and requires assistance with ADLs.
The Correct Answer is B
Choice A rationale:
A client with obsessive-compulsive disorder being upset about a change in daily routine is concerning but does not present an immediate threat to their physical health or require urgent attention compared to a potential medical emergency like a sore throat.
Choice B rationale:
Clozapine, an atypical antipsychotic, can cause agranulocytosis, a potentially life-threatening condition characterized by a severe reduction in white blood cell count. Sore throat could be an early sign of this serious adverse effect. Therefore, a client taking clozapine reporting a sore throat requires immediate evaluation to rule out agranulocytosis, which can progress rapidly if not addressed promptly.
Choice C rationale:
A client with narcissistic personality disorder mocking others during group therapy is disruptive and inappropriate behavior but does not require immediate attention unless it escalates into a situation that threatens the safety of others or the therapeutic environment.
Choice D rationale:
A client with depressive disorder requiring assistance with activities of daily living (ADLs) needs support and care, but this does not indicate an urgent situation. While assistance with ADLs is important for the client's well-being, it is not a priority over a potential medical emergency like agranulocytosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C: Initiate continuous cardiac monitoring.
Choice A rationale:
Implementing fluid restrictions is not recommended for a child with diabetic ketoacidosis (DKA). DKA is characterized by severe dehydration due to osmotic diuresis, and fluid replacement is a critical component of treatment to restore hydration and circulatory volume.
Choice B rationale:
Monitoring vital signs every 8 hours is not sufficient for a child with DKA. DKA is an acute, life-threatening condition that requires close monitoring of vital signs to detect changes in the patient’s condition promptly. Vital signs should be monitored more frequently, typically every 1 to 2 hours, depending on the severity of the DKA and institutional protocols.
Choice C rationale:
Continuous cardiac monitoring is recommended for a child with DKA. DKA can lead to serious electrolyte imbalances, such as hypokalemia, which can cause cardiac arrhythmias. Continuous cardiac monitoring allows for the early detection and treatment of these potential complications.
Choice D rationale:
Administering subcutaneous insulin 30 minutes before meals is not appropriate for the acute management of DKA. In DKA, insulin is typically administered intravenously to rapidly decrease blood glucose levels and correct metabolic acidosis. Subcutaneous insulin is not used until the patient is stable and able to eat.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale:
The client has influenza, which is a respiratory illness that can be transmitted through droplets when the infected person coughs, sneezes, or talks. The UAP is in close contact with the client while assisting them to sit up in bed to eat lunch. Therefore, it is necessary for the UAP to wear a face mask in addition to a gown and gloves to prevent the spread of the virus.This is in line with the Centers for Disease Control and Prevention (CDC) guidelines, which recommend that healthcare personnel wear a face mask when they are in the same room as a patient with suspected or confirmed influenza.
Choice B rationale:
A fitted respirator mask is not necessary in this situation.According to the Occupational Safety and Health Administration (OSHA), respirators are required for airborne diseases such as tuberculosis, but not for influenza, which is a droplet-transmitted disease. Therefore, reminding the UAP to apply a fitted respirator mask before entering the client’s room is not the most appropriate action.
Choice C rationale:
Assigning the UAP to provide care for another client and assuming full care of the client is not the most appropriate action in this situation. The UAP is already wearing a gown and gloves, which are part of the standard precautions for any patient care.The UAP just needs to add a face mask to their personal protective equipment (PPE) to safely assist the client.
Choice D rationale:
Instructing the UAP to notify the nurse of any changes in the client’s respiratory status is always a good practice. However, it does not address the immediate need for the UAP to wear a face mask while in close contact with the client. Therefore, it is not the most appropriate action in this situation.
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