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

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.

A client who is taking lithium and reports weight gain.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

A client with bipolar disorder who is speaking loudly is displaying a manic symptom, which may require attention but is not the highest priority among the options. It does not pose an immediate risk to the client's physical health.

Choice B rationale:

A client with schizophrenia experiencing olfactory hallucinations may be distressed, but this is not an immediate physical health concern. It may require attention but is not the highest priority.

Choice D rationale:

Weight gain is a potential side effect of lithium, and while it should be monitored and addressed, it is not a critical finding that requires immediate attention.

Choice C rationale:

A client taking clozapine who reports a sore throat should be seen first. Clozapine is associated with a risk of agranulocytosis, a severe condition that can lead to a dangerously low white blood cell count. A sore throat can be an early sign of infection, and in the context of clozapine use, it is crucial to assess and monitor for agranulocytosis promptly. This condition is life-threatening and requires immediate attention to prevent complications. .

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Correct Answer is A

Explanation

Choice A rationale:

(Statement then rationale) Choice A is the correct option. A blood pH of 7.60 indicates severe metabolic alkalosis, which is a life-threatening condition. Metabolic alkalosis can lead to various complications, including cardiac arrhythmias, muscle weakness, and even seizures. Immediate intervention is required to address the underlying cause and correct the pH imbalance. The nurse should initiate treatments to restore the acid-base balance promptly.

Choice B rationale:

(Statement then rationale) Choice B is not the correct option. While a BUN level of 21 mg/dL is above the normal range, it alone does not require immediate intervention. Elevated BUN can be caused by various factors and may not be immediately life-threatening. It is important to assess the client's overall clinical condition and consider other lab values to make a comprehensive assessment.

Choice C rationale:

(Statement then rationale) Choice C is not the correct option. +2 edema of the lower extremities, while indicating fluid retention, is not an immediate life-threatening condition. Edema should be assessed and addressed, but it does not require emergency intervention as much as a severely altered blood pH does.

Choice D rationale:

(Statement then rationale) Choice D is also not the correct answer. Lanugo covering the body is a physical manifestation often seen in clients with anorexia nervosa and indicates malnutrition. While it is concerning and requires attention, it is not an acute, life-threatening issue. Nutritional rehabilitation and support are needed, but immediate intervention is necessary for the severe metabolic alkalosis indicated by a blood pH of 7.60. Now, let's proceed to the next question.

A. Justice. B. Beneficence. C. Autonomy. D. Veracity.

Correct Answer is C

Explanation

Choice A rationale:

Justice refers to the fair and equitable distribution of resources and treatment, and it doesn't directly apply to the nurse supporting the client's refusal of medications.

Choice B rationale:

Beneficence involves the promotion of the client's well-being and may sometimes conflict with the client's autonomy when they refuse treatment. This choice doesn't apply to the situation where the nurse supports the client's decision to refuse medications.

Choice C rationale:

Autonomy is the ethical principle that supports an individual's right to make decisions about their own care, even if those decisions go against medical advice. In this scenario, the nurse is respecting the client's autonomy by supporting their choice to refuse medications.

Choice D rationale:

Veracity involves truth-telling and honesty in the nurse-client relationship. While it is essential, it is not the primary ethical principle being displayed when the nurse supports the client's refusal of medications.

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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 is caring for a client who has anorexia nervosa.Which of the following findings requires immediate intervention by the nurse?

Correct Answer is A

Explanation

A nurse is caring for a client who has bipolar disorder and is refusing to take prescribed medications.Which of the following ethical principles is the nurse displaying when he supports the client's refusal of medications?

Correct Answer is C

Explanation

A nurse is obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation.Which of the following assessment findings in the client's history should the nurse report to the provider?

A nurse is creating a plan of care for a client who has major depressive disorder.Which of the following interventions should the nurse include in the plan?

A nurse is assessing a client who repeatedly falsifies psychological symptoms to assume the role of a sick person.What statement is commonly associated with this behavior?

A nurse is assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on a pass during lunchtime. Which of the following assessments should the nurse perform?

A nurse is caring for a client who has a personality disorder and is using transference to cope.Which of the following behaviors should the nurse expect?

A nurse is caring for a client who has a binge eating disorder.Which of the following actions should the nurse take?

A nurse is caring for a client who has borderline personality disorder and has been engaging in self-mutilation.The nurse should encourage the client to participate in which of the following groups?

A nurse in a mental health facility is making plans for a client's discharge.Which of the following interdisciplinary team members should the nurse contact to assist the client with housing placement?

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