A nurse is caring for several clients who are attending community-based mental health programs. Which Of the following clients should the nurse plan to visit first?
Select one:
A client who recently burned her arm by accident while using a hot iron at home.
A client who tells the nurse he experienced manifestations of severe anxiety before and during a job interview.
A client who requests that her antipsychotic medication be changed due to some new adverse effects.
A client that says he is hearing a voice that tells him he is not worthy of living anymore.
The Correct Answer is D
This client is experiencing auditory hallucinations and may be at risk for self-harm or suicide. The nurse should prioritize visiting this client first to assess their safety and provide appropriate interventions.
Option a. A client who recently burned her arm by accident while using a hot iron at home may require wound care and education on safety, but this situation is not as urgent as the client experiencing auditory hallucinations.
Option b. A client who tells the nurse he experienced manifestations of severe anxiety before and during a job interview may benefit from interventions to manage anxiety, but this situation is not as urgent as the client experiencing auditory hallucinations.
Option c. A client who requests that her antipsychotic medication be changed due to some new adverse effects may require medication adjustment and monitoring for side effects, but this situation is not as urgent as the client experiencing auditory hallucinations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Diarrhea, vomiting, and drowsiness are potential signs of lithium toxicity, which can be a serious and potentially life-threatening condition. If a client who is being treated with lithium carbonate develops these symptoms, the nurse should notify the health care provider immediately and hold the next dose of medication until new orders are received from the provider.
Option a. Hold the medication and refuse to administer additional doses for 3 days is not an appropriate action because it does not involve notifying the health care provider or obtaining new orders.
Option b. Notify the health care provider immediately and give 4 liters of fluids is not an appropriate action because it involves administering fluids without obtaining orders from the health care provider.
Option d. Document the client’s symptoms and continue with medication as prescribed is not an appropriate action because it does not involve notifying the health care provider or holding the next dose of medication.
Correct Answer is A
Explanation
Individuals with OCD often engage in compulsive behaviors as a way to reduce anxiety or distress. In this case, the client’s behavior of constantly picking up after others in the day room may be a compulsion that helps them decrease their anxiety to a tolerable level.
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