A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

A client who is taking lithium and reports weight gain

A client who has bipolar disorder and is speaking loudly

A client who has schizophrenia and is experiencing olfactory hallucinations

A client who is taking clozapine and reports a sore throat

Answer and Explanation

The Correct Answer is D

Clozapine is an antipsychotic medication that can cause agranulocytosis, a potentially life-threatening condition that reduces the number of white blood cells and increases the risk of infection. A sore throat is a sign of infection and should be reported immediately. The other clients are not in immediate danger and can be seen later.

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Correct Answer is B

Explanation

The nurse's priority is to ensure that the child is safe and protected from further harm. A spiral fracture is a type of fracture that occurs when a bone is twisted, and it is often associated with child abuse. The nurse should assess if there are any other signs of abuse, such as bruises, burns, or cuts, and if there are any threats to the child's well-being at home or elsewhere. The nurse should also provide emotional support and comfort to thechild. The other options are important steps to take, but they are not as urgent as ensuring safety.

A. A client who has stomach pain before presenting a project to his coworkers. B. A client whose partner died 5 years ago still talks about him in the present tense. C. A client who states she will worry about her grades after she finishes planning a party. D. A client who states she did not get a promotion because her boss dislikes her.

Correct Answer is D

Explanation

Rationalization is a defense mechanism that involves making excuses or justifying one's behavior or failures. The client who blames their boss for not getting a promotion is using rationalization to avoid accepting responsibility or acknowledging their shortcomings. The other examples are not related to rationalization, but to other defense mechanisms, such as somatization, denial, and procrastination.

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A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is assessing a school-age child who has a spiral fracture. The parent of the child provides different accounts of the cause of the injury. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A charge nurse is educating a newly licensed nurse about various defense mechanisms. Which of the following examples should the charge nurse provide when discussing rationalization?

Correct Answer is D

Explanation

A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?

A home health nurse is caring for a client who is in the continuation phase of major depressive disorder. The client states, "I feel unmotivated and don't feel like leaving my home." Which of the following recommendations should the nurse make to address the client's social isolation?

A nurse is providing counseling for a family that consists of two parents and their two adolescent children. Which of the following family members should the nurse identify as acting in the role of monopolizer?

A nurse is leading a grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression?

A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?

A nurse is planning to conduct a support group for adolescents who have cancer. Which of the following actions should the nurse include during the orientation phase?

A charge nurse is making room assignments for new client admissions. Which of the following clients should the nurse place closest to the nurse's station?

A nurse is caring for a client who has been taking valproic acid. Which of the following is an expected outcome of the medication?