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. This statement indicates an understanding of the needs of clients who are part of vulnerable populations because it demonstrates an awareness of the importance of client-centered care. Addressing the problem that the client believes is the most significant acknowledges the client's autonomy, respects their perspective, and ensures that their needs are prioritized.
A. This statement suggests a narrow focus on the immediate reason for the client's visit. While addressing the client's presenting concern is important, a limited assessment may overlook underlying issues or social determinants of health that could impact the client's well-being.
B. While privacy is important, asking clients for income or financial information may be necessary to assess their eligibility for financial assistance programs or to understand socioeconomic factors that may impact their health and access to care.
D. This statement suggests overlooking the importance of cultural competence in nursing practice. Cultural traditions, beliefs, and practices can significantly influence a client's health beliefs, behaviors, and preferences for care.
Correct Answer is D
Explanation
D Tertiary prevention aims to minimize the impact of an existing illness or condition and prevent further complications or recurrence. In the context of substance use disorder, providing information on drug rehabilitation facilities aligns with tertiary prevention strategies.
A. This intervention is more aligned with primary or secondary prevention strategies aimed at preventing substance use disorder or addressing risk factors before the onset of the disorder. B This intervention is focused on screening for a potential complication or comorbidity associated with substance use disorder rather than providing treatment or support for the disorder itself.
C- Secondary prevention
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