A nurse is caring for multiple clients on a mental health unit.
Which of the following clients should the nurse attend to first?
A client who is repeatedly approaching the nurses' station to request medication for his anxiety.
A client who is standing in her room, yelling obscenities, and throwing her clothes.
A client who has bipolar disorder and is continuously pacing at the end of the hall.
A client in the dayroom who is screaming at other clients about what is on the television.
The Correct Answer is B
Choice A rationale
While this client may need attention, the behavior is not immediately dangerous.
Choice B rationale
This client requires immediate attention due to the risk of harm to herself and others through throwing objects and yelling, which indicates potential for escalation.
Choice C rationale
Pacing, although concerning, does not pose an immediate risk of physical harm compared to Choice B.
Choice D rationale
The client is disruptive but not immediately dangerous compared to the client in Choice B who poses a more direct risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Cold extremities are a common finding in individuals with anorexia nervosa due to poor circulation and reduced body fat, which impairs the body's ability to maintain normal temperature.
Choice B rationale
Diarrhea is not typically associated with anorexia nervosa. Instead, individuals with this disorder often experience constipation due to restrictive eating and decreased bowel movements.
Choice C rationale
Tooth erosion is a common finding in individuals with anorexia nervosa, particularly those who engage in self-induced vomiting, as stomach acid erodes the enamel on teeth.
Choice D rationale
Lanugo, or fine, soft body hair, is a common finding in individuals with anorexia nervosa as the body attempts to conserve heat due to loss of insulating body fat.
Correct Answer is A
Explanation
Choice A rationale
A fluctuating level of orientation is a hallmark sign of delirium. Delirium is characterized by an acute and fluctuating course of altered mental status, including changes in attention, awareness, and cognition.
Choice B rationale
A consistent state of depression is not indicative of delirium. While depression can affect mental status, it does not typically present with the acute, fluctuating changes seen in delirium.
Choice C rationale
Demonstrating obsessive behaviors is more characteristic of obsessive-compulsive disorder and does not typically indicate delirium.
Choice D rationale
Short-term memory loss can be a feature of many conditions, including dementia, but does not specifically indicate delirium, which is distinguished by its rapid onset and fluctuating nature. .
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