A nurse is caring for a client who has a serious mental illness. The client's temperature is 37° C (98.6° F), respiratory rate is 18/min, heart rate is 102/min, and blood pressure is 202/98 mm Hg. The client is wearing a heavy coat and scarf. The temperature is 37.8° C (100° F) outside. The client reaches for the nurse and says. "Kiss me baby! You know you want to!" Which of the following findings should the nurse address first?
Blood pressure
Heart rate
Comment to the nurse
Clothing choice of heavy coat
The Correct Answer is C
C. The nurse should address the client's inappropriate and boundary-crossing behavior first. The client's statement, "Kiss me baby! You know you want to!" is suggestive and inappropriate in a professional healthcare setting. It indicates a lack of understanding or disregard for appropriate social boundaries and may be a manifestation of the client's serious mental illness.
A, B, D- While the client's vital signs (blood pressure, heart rate, respiratory rate, and temperature) and clothing choice (wearing a heavy coat and scarf in warm weather) may be important to assess and address, the immediate priority is to address the client's inappropriate behavior and ensure a safe and therapeutic environment for both the client and the nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Dissociative identity disorder (DID) can affect individuals of any age, including children. While treatment approaches may vary depending on the age of the individual and their specific needs, one aspect that remains consistent across age groups is the importance of assessing for thoughts of self-harm or suicidal ideation.
A. Nursing interventions for dissociative identity disorder (DID) can be diverse and tailored to the individual needs of the patient, regardless of age. While managing DID in children may present some unique challenges compared to adults, it doesn't mean that nursing interventions are limited. This option may not provide helpful information to the guardian seeking guidance.
C. Treatment outcomes for DID can vary widely depending on various factors, including the severity of symptoms, the presence of comorbid conditions, the quality of therapeutic interventions, and the individual's support system. While some older individuals may respond well to treatment, age alone is not a determining factor in treatment outcomes.
D. Dissociative identity disorder can occur in both children and adults, and psychiatric medication may be prescribed to individuals of any age depending on the severity of symptoms and individual treatment plans. Medication is often used to manage comorbid conditions such as depression, anxiety, or mood disorders that commonly co- occur with DID.
Correct Answer is C
Explanation
C. Vulnerable populations, such as those with low socioeconomic status, the elderly, racial and ethnic minorities, and individuals with certain health conditions, may experience higher levels of health risks due to various factors such as limited access to healthcare, environmental exposures, social determinants of health, and underlying health disparities.
A. Although variability of response to stressors is important it is not the primary concern
B. Although older individuals are vulnerable to risk factors, the nurse should include all vulnerable groups.
D. While resilience can mitigate the impact of risk factors on health outcomes, it is not a determinant of health risk itself.
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