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:

Hypertension, while a medical condition, is not a direct risk factor for delirium. Delirium is typically associated with factors such as infection, medication side effects, metabolic imbalances, or acute changes in medical conditions, rather than chronic conditions like hypertension.

Choice B rationale:

Neuropathy is also not a direct risk factor for delirium. Delirium is more commonly associated with acute changes in neurological status or conditions that affect brain function.

Choice C rationale:

A white blood cell (WBC) count of 13,000/mm³ is an elevated count and may indicate an underlying infection or inflammation. Infection and inflammation are common causes of delirium, making an elevated WBC count a potential risk factor for developing delirium.

Choice D rationale:

A blood urea nitrogen (BUN) level of 16 mg/dL is slightly elevated but is not a direct risk factor for delirium. Delirium is more often associated with metabolic imbalances, electrolyte abnormalities, or acute changes in kidney function. A BUN level of 16 mg/dL alone is not a major contributor to delirium. .

A. "How have you dealt with similar situations in the past?". B. "Can you describe how you are currently feeling?". C. "Do you see your current situation affecting your future?". D. "How does this situation affect your life?".

Correct Answer is A

Explanation

Choice A rationale:

The nurse should ask the client, "How have you dealt with similar situations in the past?" This question is essential to assess the client's personal coping skills. By inquiring about the client's previous experiences in handling similar situations, the nurse can gain insight into the client's coping mechanisms and identify potential strengths and weaknesses. Understanding how the client has coped in the past can help tailor interventions and support to their specific needs.

Choice B rationale:

While asking, "Can you describe how you are currently feeling?" is a valuable question, it primarily focuses on the client's current emotional state and may not provide a comprehensive assessment of their coping skills. It is crucial to understand the client's emotions, but it does not directly address their coping strategies.

Choice C rationale:

"Do you see your current situation affecting your future?" is a forward-looking question that explores the client's perception of how their current situation might impact their future. While this question is relevant, it does not directly assess the client's coping skills and strategies. It focuses more on the client's expectations and outlook.

Choice D rationale:

"How does this situation affect your life?" is a broad question that can provide insights into the client's life and the impact of their current situation. However, it does not specifically address the client's coping skills and strategies. It may provide information about the consequences of their situation but not their ability to cope.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is caring for a client.The nurse should identify that which of the following conditions places the client at an increased risk for developing delirium?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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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?