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 In Alzheimer's disease, cortical thinning typically begins in the temporal and parietal lobes of the brain, areas associated with memory, language, and higher cognitive functions. As the disease progresses, cortical thinning may extend to other regions of the brain, contributing to the worsening cognitive decline seen in affected individuals.
A. HIV-associated neurocognitive disorders (HAND) can result in various structural and functional changes in the brain, including cortical atrophy, but cortical thinning is not a specific hallmark of HIV infection-related dementia.
C. Prion diseases can lead to spongiform changes and neuronal loss in the brain, but cortical thinning is not typically described as a characteristic feature.
D. Chronic substance abuse, particularly alcohol and certain drugs, can lead to structural and functional changes in the brain, including cortical atrophy. However, cortical thinning is not specific to substance use disorder-related dementia and can occur in various other neurological conditions as well.
Correct Answer is D
Explanation
D. Mental illness is complex and multifactorial, and the response to medication can vary widely among individuals. While medication can be effective in alleviating symptoms for many people, factors such as genetic predisposition, neurobiological differences, environmental influences, and individual variability in brain function and structure can all impact treatment response.
A. While medication adherence is important for managing mental illness, it is rarely a cure on its own. Mental illness often requires ongoing treatment and management.
B. Some individuals may experience rapid improvement with medication, while others may take longer to see results or may require adjustments to their treatment plan.
C. Mental illness is not solely determined by willpower, and implying that it is oversimplifies the complex nature of these conditions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.