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
Russell’s sign is a physical symptom that is associated with bulimia nervosa. It refers to the presence of calluses on the knuckles or back of the hand that are caused by repeated self-induced vomiting.
Option a. Very low BMI is not typically associated with bulimia nervosa. People with bulimia nervosa may have a normal or above-normal BMI.
Option b. Decreased size of parotid glands is not associated with bulimia nervosa. In fact, people with bulimia nervosa may have an enlarged parotid gland due to repeated vomiting.
Option d. Fluid and electrolyte overload is not typically associated with bulimia nervosa. People with bulimia nervosa may experience fluid and electrolyte imbalances due to repeated vomiting and laxative abuse.
Correct Answer is D
Explanation
During a crisis, the client may be at risk of harming themselves or others. The nurse should take steps to ensure the safety of the client and those around them. Once the immediate safety concerns have been addressed, the nurse can then focus on identifying the cause of the client’s anxiety and helping them develop coping skills.
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