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A nurse is assisting in the care of a client in the emergency department (ED). Nurses' Notes 0205: Client brought to the ED by police after being found wandering on the street.

Client able to provide identity to police but not able to identify place or time.

Family notified.

Client confused and agitated.

Appearance is disheveled.

Mucous membranes dry.

Lungs clear and equal, heart rhythm regular.

During data collection, the client states, "Can you ask that person to leave my room?" Client is pointing to an empty chair.

Vital Signs 0200: Temperature 38.6°C (101.5°F), Heart rate 104/min, Respiratory rate 18/min, Blood pressure 158/96 mm Hg, Oxygen saturation 98% on room air.

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Client confused and agitated.

Appearance is disheveled.

Mucous membranes dry

client states, "Can you ask that person to leave my room?"

Client is pointing to an empty chair

Temperature 38.6°C (101.5°F)

Blood pressure 158/96 mm Hg

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F","G"]

The findings that require immediate follow-up are: Client confused and agitated: This could indicate a neurological issue or other serious condition that needs immediate attention.
Appearance is disheveled: This could suggest neglect or other issues that need to be addressed.
Mucous membranes dry: This could indicate dehydration which can be serious if not addressed promptly. Client states “Can you ask that person to leave my room?” Client is pointing to an empty chair: This could indicate hallucinations or other mental health concerns that need immediate attention.
Temperature 38.6°C (101.5°F): This is a fever and could indicate an infection or other medical condition that needs immediate attention.
Blood pressure 158/96 mm Hg: This is high and could indicate hypertension or other cardiovascular issues that need immediate attention.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Choice A rationale:

Suppression is a conscious decision to delay paying attention to an emotion or need in order to cope with the present reality. In this case, the client is choosing to delay thinking about their health until after their son’s wedding.

Choice B rationale:

Reaction formation is behaving in a way that is exactly the opposite of one’s true feelings. This is not evident in the client’s statement.

Choice C rationale:

Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image. This is not evident in the client’s statement.

Choice D rationale:

Projection is attributing one’s unacceptable thoughts and feelings onto another who does not have them. This is not evident in the client’s statement.

A. Client confused and agitated. B. Appearance is disheveled. C. Mucous membranes dry D. client states, "Can you ask that person to leave my room?" E. Client is pointing to an empty chair F. Temperature 38.6°C (101.5°F) G. Blood pressure 158/96 mm Hg

Correct Answer is ["A","B","C","D","E","F","G"]

Explanation

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new diagnosis of cancer. The client states, "I can't think about my health until after my son is married next week.”. The nurse should identify the client's statement as an indication of which of the following maladaptive defense mechanisms?.

Correct Answer is A

Explanation

Correct Answer is ["A","B","C","D","E","F","G"]

Explanation

A nurse in a mental health facility is caring for an adolescent who is newly admitted for an overdose of prescription pain medication. The client has prescriptions for an anxiolytic and an SSRI antidepressant. Which of the following precautions should the nurse take?.

A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior. Which of the following actions should the nurse take?.

A nurse is caring for multiple clients on a mental health unit. Which of the following clients should the nurse attend to first?.

A nurse is collecting data from an older adult client who was admitted with heart failure. The nurse should report which of the following findings to the provider as an indication of delirium? .

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A nurse is collecting data from a client who experienced physical abuse as a child. Which of the following findings should the nurse identify as a risk factor for the client to become a perpetrator of child abuse?.

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