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

Answer and Explanation

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.

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Correct Answer is B

Explanation

B. Somatic symptom disorder (SSD) involves persistent, distressing physical symptoms along with excessive thoughts, feelings, or behaviors related to those symptoms. While SSD can occur at any age, it is often underdiagnosed in the older population. Older adults may present with various somatic complaints, which can sometimes be mistaken for age-related physical health issues rather than manifestations of a psychological disorder.

A. The learner's ability to perform a skill B. The learner's desire to participate C. The learner's knowledge and skill level D. The learner's feelings, beliefs, and attitudes

Correct Answer is D

Explanation

D. The affective domain of learning involves the development of attitudes, values, beliefs, and emotions. It encompasses the learner's internalization of values, appreciation, motivation, and the development of a positive attitude towards learning.

A. This refers to the psychomotor domain of learning, which involves the development of physical skills and coordination. It includes actions such as manipulation, coordination, and movement.

B. This relates to motivation and engagement, which can influence the learner's level of involvement and commitment to the learning process.

C. This pertains to the cognitive domain of learning, which involves the acquisition of knowledge, comprehension, application, analysis, synthesis, and evaluation of information. It encompasses intellectual abilities such as understanding, reasoning, problem-solving, and critical thinking.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is working with an older adult client who has been diagnosed with somatic symptom disorder. Which of the following should the nurse consider when working with an older adult who has somatic symptom disorder?

Correct Answer is B

Explanation

A community health nurse is preparing an educational activity that addresses the domains of learning. The nurse should know that the affective domain focuses on which of the following?

Correct Answer is D

Explanation

A nurse is caring for a client who regularly uses methamphetamine and is experiencing blood vessel constriction and spasming. The nurse should identity that the client is at high risk for developing which of the following conditions?

A nurse is preparing a presentation about alcohol withdrawal. Which of the following findings should the nurse include in the presentation?

A nurse is caring for a client who has schizophrenia. Which of the following findings should the nurse identify as a comorbidity to this condition?

A nurse is discussing schizophrenia spectrum disorders with a client. The client states, "My friend says that before I started hearing voices. I stopped hanging out with them. Why is that?" Which of the following responses should the nurse make?

A nurse is assessing a 10-year-old child who has an autism spectrum disorder. Which of the following findings are expected?

A nurse is presenting information about the prevention of sexually transmitted infections to a group of high school students. The nurse should identify that this is an example of which of the following types of prevention?

A nurse is caring for a client who asks the nurse, "May I please have your home address so that I can send you a note after I get home?" Which of the following responses should the nurse give?

A nurse is providing education about somatic symptom disorder to a client's family. Which of the following pieces of information should the nurse include in the education?