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 C

Explanation

Choice A rationale:

"I'm struggling with altered motor function.”. This statement is more in line with a description of conversion disorder or functional neurological symptom disorder, where clients may experience symptoms like paralysis or altered motor function, but these symptoms are typically not intentionally produced for attention-seeking purposes.

Choice B rationale:

"I don't know why I'm feeling this way.”. This statement does not specifically indicate a deliberate intent to falsify psychological symptoms for attention. It could be related to other emotional or psychological issues, but it doesn't directly relate to the behavior described in the question.

Choice D rationale:

"I'm worried about having a serious illness.”. This statement reflects concerns about actual medical conditions and does not align with the behavior of repeatedly falsifying psychological symptoms for attention. People with factitious disorder may feign physical symptoms but not necessarily express concerns about having a serious illness themselves. Now, let's address the last question.

A. "How do you think this event is affecting your life right now?". B. "Are you having thoughts about harming yourself?". C. "What do you usually do to cope with problems in your life?". D. "Who do you talk to when you need help?".

Correct Answer is B

Explanation

Choice A rationale:

Asking how the event is affecting the client's life is important, but it is not the priority during a situational crisis. Safety and assessing for self-harm thoughts come first.

Choice B rationale:

This question is the priority because it assesses the client's safety and potential for self-harm, which is crucial during a crisis. If the client is having thoughts of self-harm, immediate intervention is required.

Choice C rationale:

Inquiring about the client's coping strategies is relevant, but it is not the primary concern when there is a potential risk of self-harm.

Choice D rationale:

Asking about who the client talks to for help is important but not the primary concern in a situation where self-harm may be a risk.

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

Correct Answer is C

Explanation

A nurse is assessing a client who recently experienced the loss of their partner.Which of the following questions is the priority for the nurse to ask during this situational crisis?

Correct Answer is B

Explanation

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A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?

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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?