A nurse in an acute mental health facility receives change-of-shift report on a group of clients. Which of the following clients should the nurse assess first?

A client who has borderline personality disorder and exhibits splitting behaviors

A client who has schizophrenia and reports command hallucinations

A client who recently started taking lithium and has a fine hand tremor

A client who takes nicotine and states they have a dry mouth

Answer and Explanation

The Correct Answer is B

A. A client who has borderline personality disorder and exhibits splitting behaviors

While splitting behaviors can be concerning and may require intervention, they do not typically pose an immediate threat to the client's safety or well-being compared to other urgent issues such as hallucinations or medication side effects.

B. A client who has schizophrenia and reports command hallucinations

Command hallucinations can be dangerous as they may prompt the client to engage in harmful behaviors or actions directed by the hallucinations. Therefore, this client should be assessed first to ensure their safety and intervene if necessary.

C. A client who recently started taking lithium and has a fine hand tremor

A fine hand tremor is a common side effect of lithium therapy and typically does not require immediate attention unless it becomes severe or interferes significantly with the client's functioning. Therefore, this client's assessment can be prioritized lower than the client experiencing command hallucinations.

D. A client who takes nicotine and states they have a dry mouth

While a dry mouth can be uncomfortable, it is not typically a critical issue requiring immediate assessment compared to the safety concerns associated with command hallucinations in a client with schizophrenia.

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Correct Answer is B

Explanation

A. Keep the client hospitalized until there is no longer a threat

Nurses do not have the authority to unilaterally detain clients in a hospital. This decision is typically made by a physician or a legal authority, especially in the context of a medical-surgical unit where mental health professionals may need to be involved.Keeping a client hospitalized without proper legal procedures and mental health evaluation could lead to legal repercussions for unlawful detainment.

B. Ensure the client's ex-partner is notified of the threat

This option involves notifying the potential victim about the threat made by the client. While it's important to ensure the safety of others, the nurse's legal duty primarily lies with protecting the confidentiality of the client's information. Without consent from the client or a legal obligation, such as mandatory reporting laws for imminent harm, the nurse cannot disclose the threat to the ex-partner.

C. Ask a friend or family member to monitor the client

While involving family or friends might provide support, it is not a sufficient or appropriate response to a threat of harm. It does not address the immediate risk posed to the ex-partner and may not comply with legal obligations.

D. Transfer the client to a mental health facility

Transferring the client to a mental health facility for further evaluation and treatment might be necessary, but it must be done through appropriate medical and legal channels. It addresses the need for a thorough mental health assessment and ensures that the client receives the necessary care.

A. Flight of ideas B. Word salad C. Neologisms D. Clang associations

Correct Answer is B

Explanation

A. Flight of ideas: This speech pattern is characterized by rapidly shifting from one idea to another that are unrelated or loosely related. It often reflects disorganized thinking seen in conditions like mania or schizophrenia.

B. Word salad: Word salad refers to a jumble of words and phrases that lack coherence or meaning. It typically involves random or illogical word combinations that do not make sense when put together.

C. Neologisms: Neologisms are newly created words or phrases that have meaning only to the individual. They may be completely invented or may have personal significance to the speaker but are not understood by others.

D. Clang associations: Clang associations involve the stringing together of words based on similar sounds rather than logical connections. It often results in rhyming or repetitive speech patterns that lack coherence.

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A nurse in an acute mental health facility receives change-of-shift report on a group of clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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