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 C
Explanation
Choice A rationale
Recreational therapy may be beneficial, but it is not the primary intervention to reduce the risk of falls.
Choice B rationale
Lowering the window shade could help with sensory overload, but it does not directly address fall prevention.
Choice C rationale
Placing the client near the nurses' station allows for closer monitoring and quicker intervention, which can help prevent falls.
Choice D rationale
Vest restraints should only be used as a last resort after other less restrictive measures have been tried and found ineffective.
Correct Answer is B
Explanation
Choice A rationale
Bulimia nervosa primarily affects the gastrointestinal system, dental health, and electrolyte balance. While there are health risks, diabetes mellitus is not directly associated with bulimia nervosa.
Choice B rationale
Individuals with bulimia nervosa often maintain an average or ideal body weight, which makes the disorder less visible compared to anorexia nervosa.
Choice C rationale
Bulimia nervosa is characterized by episodes of binge eating followed by compensatory behaviors such as vomiting, not by average food consumption.
Choice D rationale
The absence of vomiting does not rule out bulimia nervosa, as individuals may engage in other compensatory behaviors like excessive exercise or fasting.
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