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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.4"]
Explanation
To find out how many milliliters (mL) the nurse should administer, we first need to determine the total dose required per administration. The client is receiving haloperidol 2 mg IM every 6 hours.
First, let's calculate the total dose required per administration:
2 mg (total dose) / 1 dose = 2 mg
Next, we need to determine how many milliliters (mL) of the medication solution contain this dose. The concentration of the haloperidol solution is 5 mg/mL.
We can set up a proportion to find the volume of the solution:
2 mg (dose required) / x mL (volume to administer) = 5 mg/mL (concentration)
Cross-multiplying:
2 mg * 1 mL = 5 mg * x mL
2 mL = 5x
To isolate x (the volume to administer), we divide both sides by 5:
x = 2 mL / 5
x = 0.4 mL
So, the nurse should administer 0.4 mL of haloperidol
Correct Answer is A
Explanation
A. “If I drink alcohol I will become very sick.”: This statement accurately reflects the purpose of disulfiram. Disulfiram works by causing unpleasant physical symptoms, such as nausea, vomiting, and flushing, if alcohol is consumed, thereby deterring the individual from drinking.
B. “If I drink alcohol I will not be able to fall asleep.”: This statement does not accurately reflect the effects of disulfiram. Disulfiram does not typically affect sleep patterns directly; its effects are related to the ingestion of alcohol.
C. “If I drink alcohol will lose control of my inhibitions and say something I don’t mean.”: This statement does not accurately reflect the effects of disulfiram. Disulfiram does not directly affect inhibitions or speech patterns; its effects are related to physical symptoms caused by alcohol ingestion.
D. "If I drink alcohol will have severe mood swings.”: This statement does not accurately reflect the effects of disulfiram. Disulfiram does not typically cause mood swings; its effects are related to physical symptoms induced by alcohol ingestion.
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