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 A
Explanation
A. Families where caregivers have higher levels of education, such as college degrees or higher, tend to have more access to resources, support networks, and knowledge about child development and parenting practices. This can contribute to a more stable and nurturing environment for children, reducing the likelihood of adverse childhood experiences.
B. This option describes a lack of emotional support and connection within the family, which is considered a risk factor rather than a protective factor for adverse childhood experiences.
C. Social isolation can contribute to increased stress and lack of support for both children and caregivers, which may exacerbate the impact of adverse childhood experiences.
D. While single parenthood or having young caregivers may present additional challenges, it is not inherently a risk factor for adverse childhood experiences.
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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