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
Choice A rationale: Hypoglycemia refers to low blood sugar levels. This condition can occur in newborns, especially those born to mothers with diabetes, preterm babies, babies who are small for gestational age, or those who have experienced a difficult delivery. However, the provided information does not indicate any signs of hypoglycemia such as jitteriness, poor feeding, or lethargy.
Choice B rationale: Bronchopulmonary dysplasia (BPD) is a chronic lung disease that affects newborns and infants. It’s more common in premature infants who have received oxygen therapy or mechanical ventilation. The newborn’s information does not suggest any risk factors for BPD.
Choice C rationale: Transient tachypnea of the newborn (TTN) is a respiratory problem that can be seen shortly after delivery in babies who have no other health issues. It’s caused by fluid in the lungs. The newborn’s increased respiratory rate and grunting are signs of TTN. This condition is more common in babies delivered via cesarean birth, as in this case.
Choice D rationale: Tachycardia refers to a heart rate that’s too fast. While the newborn’s heart rate is on the higher side of normal (normal range: 120-160 beats per minute), it’s not high enough to be considered tachycardia. Therefore, based on the provided information, the newborn is at risk for developing Transient tachypnea of the newborn (Choice C). The other conditions mentioned do not align with the symptoms and risk factors presented in the scenario.
Correct Answer is A
Explanation
Choice A rationale:
Encouraging fluid intake of 2,500 mL/day is the correct choice for a client with a fever due to an infection. Adequate hydration is essential in managing fever as it helps to prevent dehydration, maintain electrolyte balance, and support the body's immune response. Increasing fluid intake, preferably water, can also aid in lowering body temperature and promoting overall comfort.
Choice B rationale:
Maintaining the environmental temperature at 16°C to 18°C (60°F to 65°F) is not an appropriate intervention for a client with a fever. While it's essential to keep the client comfortable, adjusting the room temperature within a specific range is not the primary intervention. Focus should be on managing the fever through hydration, antipyretic medications, and addressing the underlying infection.
Choice C rationale:
Immersing the client in cold water is not a recommended intervention for managing fever. Cold water immersion can lead to shock, vasoconstriction, and potentially worsen the condition. It is essential to use methods like tepid sponging or cooling blankets if necessary, but these interventions should be performed under healthcare provider guidance and monitoring.
Choice D rationale:
Assisting the client to ambulate is a general nursing care activity and does not specifically address the fever due to infection. While ambulation is encouraged for many patients to prevent complications related to immobility, it is not the primary intervention for managing fever. The focus should be on hydration and other appropriate measures to reduce fever.
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