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 D

Explanation

A. A client who has new-onset delirium: Delirium is characterized by acute confusion and changes in cognition, often due to underlying medical conditions. Assertiveness training may not be appropriate for someone experiencing delirium, as their cognitive impairment may interfere with their ability to participate effectively in the therapy session.

B. A client who is experiencing auditory hallucinations: Auditory hallucinations involve perceiving sounds or voices that are not actually present. Assertiveness training may not directly address the underlying cause of auditory hallucinations, which typically require other therapeutic approaches such as medication management and cognitive-behavioral therapy.

C. A client who is experiencing mania: Mania is a state of elevated mood, increased energy, and often impulsivity. While assertiveness training could potentially be beneficial for individuals with bipolar disorder during periods of stability, it may not be appropriate during acute manic episodes when the client's judgment and insight may be impaired.

D. A client who has somatic symptom disorder: Somatic symptom disorder involves experiencing distressing physical symptoms that are disproportionate to any identified medical condition. Assertiveness training could be helpful for individuals with somatic symptom disorder to effectively communicate their concerns with healthcare providers and advocate for appropriate care.

A. Provide additional attention to the client B. Apply mechanical restraints before administering medication C. Obtain a verbal contract from the client D. Limit staff members who work with the client

Correct Answer is C

Explanation

A. Provide additional attention to the client: While individuals with BPD may crave attention and validation, providing excessive attention can reinforce maladaptive behaviors. Instead, the focus should be on providing consistent and appropriate support while also setting boundaries to encourage healthy coping mechanisms.

B. Apply mechanical restraints before administering medication: Mechanical restraints should only be used as a last resort when less restrictive interventions have failed to ensure the safety of the client and others. Applying restraints before attempting other interventions is not appropriate and may escalate the situation.

C. Obtain a verbal contract from the client: A verbal contract is an agreement between the client and the treatment team regarding safety measures and coping strategies. This intervention involves collaboratively establishing agreements with the client, which can help empower them to take responsibility for their behaviors and engage in treatment planning.

D. Limit staff members who work with the client: Limiting staff members who work with the client may inadvertently isolate the client and hinder the development of therapeutic relationships. Consistency in staffing and a collaborative approach among team members are often more beneficial in providing comprehensive care.

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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 D

Explanation

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Correct Answer is C

Explanation

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