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 C
Explanation
C. Reinforcing teaching with vulnerable clients about strategies to prevent illness and promote health is the most immediate and direct action the nurse can take. Education empowers
individuals to make informed decisions about their health and well-being, potentially preventing illness and reducing the need for healthcare services.
A. This action focuses on improving access to care but may not directly address the immediate health needs of vulnerable clients.
B. Protecting the rights and well-being of clients without housing is important, but it may take time to implement legislative changes and see the effects.
D. While advocating for policy change and advising elected officials on the needs of vulnerable populations is important for systemic change, it may not directly address the immediate health needs of vulnerable clients
Correct Answer is A
Explanation
A. Interpersonal therapy (IPT) focuses on improving interpersonal relationships and social functioning, which is crucial for individuals with avoidant personality disorder. This therapy helps clients work through feelings of inadequacy, sensitivity to criticism, and fear of rejection, aiming to enhance their ability to connect with others and improve their social skills.
B. Antipsychotic medications are primarily used to treat psychotic disorders such as schizophrenia and bipolar disorder with psychotic features. They are not the first-line treatment for avoidant personality disorder.
C. While DBT is useful for emotional regulation and has applications in various personality disorders, it is primarily designed for borderline personality disorder and may not be the first choice for avoidant personality disorder.
D Dialectical behavior therapy (DBT) is a type of cognitive-behavioral therapy (CBT) that emphasizes acceptance and change strategies.
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.