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 B
Explanation
Choice A rationale
Making a unit calendar helps with orientation but doesn't specifically engage reminiscence therapy, which focuses on recalling past experiences.
Choice B rationale
Discussing childhood memories fosters reminiscence, aiding in cognitive stimulation and emotional connection among older adults.
Choice C rationale
Thought-stopping techniques are more suited for managing negative thoughts in disorders like anxiety or depression, not for reminiscence therapy.
Choice D rationale
Playing board games enhances cognition but doesn't specifically target reminiscence, which involves sharing and discussing past experiences.
Correct Answer is B
Explanation
Choice A rationale
Increasing the client's daily caloric intake is not an intervention specifically recommended for clients taking lithium. Lithium therapy requires monitoring of fluid and electrolyte balance, but there is no specific recommendation to increase caloric intake as part of the treatment plan.
Choice B rationale
Administering lithium with meals is recommended to reduce gastrointestinal upset. Lithium can cause stomach irritation, and taking it with food helps minimize this side effect, improving the client's comfort and adherence to the medication regimen.
Choice C rationale
Monitoring for hypoglycemia is not a standard intervention for clients taking lithium. Lithium primarily affects fluid and electrolyte balance, particularly sodium levels, but it is not associated with causing hypoglycemia. Monitoring for lithium toxicity and maintaining appropriate hydration are more critical aspects of care.
Choice D rationale
Decreasing dietary potassium is not required for clients taking lithium. Lithium does not affect potassium levels significantly, and there is no need to modify potassium intake. The focus should be on maintaining adequate hydration and monitoring lithium levels to avoid toxicity.
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