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 A

Explanation

A. "Has a family member indicated that you should cut down on your drinking?”: This question assesses whether there have been any external concerns or criticisms related to the client's alcohol consumption, which is a common feature in alcohol use disorder.

B. “Have you had a glass of wine in the last week?”: While this question assesses recent alcohol consumption, it does not specifically address problematic drinking patterns or consequences associated with alcohol use disorder.

C. “Do you drink alcohol with your friends?”: This question addresses social drinking behavior but does not specifically focus on the potential for alcohol use disorder or problematic drinking patterns.

D. "Do you enjoy drinking alcohol?”: While enjoyment of alcohol may be relevant to the overall assessment, it does not specifically address problematic drinking patterns or consequences associated with alcohol use disorder.

A. “ECT contraindicated in clients who have psychotic symptoms.” B. "ECT is delivered through electrodes attached to the head.” C. ECT cannot be administered to clients who have suicide ideation D. ECT is conducted under regional anesthesia.

Correct Answer is B

Explanation

A. “ECT contraindicated in clients who have psychotic symptoms.”: This statement is incorrect. ECT can be used to treat various mental health conditions, including severe depression with psychotic features. It is not contraindicated solely based on the presence of psychotic symptoms.

B. "ECT is delivered through electrodes attached to the head.”: This statement is accurate. Electroconvulsive therapy (ECT) involves the delivery of electrical currents to the brain through electrodes placed on the scalp. These electrodes are positioned to target specific areas of the brain.

C. “ECT cannot be administered to clients who have suicide ideation”: This statement is incorrect. ECT can be considered as a treatment option for individuals with severe depression, including those with suicidal ideation or behavior. It can be effective in rapidly alleviating symptoms and reducing suicide risk in some cases.

D. “ECT is conducted under regional anesthesia.”: This statement is incorrect. Electroconvulsive therapy (ECT) is typically performed under general anesthesia to ensure the client's comfort and safety during the procedure. Regional anesthesia is not commonly used for ECT.

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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 A

Explanation

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Correct Answer is B

Explanation

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