A nurse is receiving change-of-shift report on a group of clients. Which of the following clients should the nurse see first?
A client who is exhibiting flight of ideas
A client who refuses to attend group therapy
A client who is experiencing a moderate level of anxiety
A client who is having command hallucinations
The Correct Answer is D
A. A client who is exhibiting flight of ideas: Flight of ideas indicates pressured, rapid speech and distractibility often seen in mania. While this requires monitoring and support, it does not pose an immediate risk of harm to the client or others.
B. A client who refuses to attend group therapy: Refusal to attend therapy reflects a non-urgent behavioral issue. The client’s autonomy should be respected, and interventions can be planned after more urgent concerns are addressed.
C. A client who is experiencing a moderate level of anxiety: Moderate anxiety may cause discomfort and decreased coping, but it does not typically create an immediate threat to safety. The nurse can intervene with calming techniques and support in a timely manner.
D. A client who is having command hallucinations: Command hallucinations can instruct the client to harm themselves or others, representing an immediate safety risk. The nurse should assess this client first to implement interventions that prevent potential harm and ensure safety on the unit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. History of renal calculi: Kidney stones do not directly increase the risk of complications from oral contraceptives. While maintaining hydration is important, a history of renal calculi is not considered a contraindication to combined hormonal contraceptive use.
B. Migraines with aura: Migraines with aura are associated with an increased risk of ischemic stroke, which is further elevated by estrogen-containing oral contraceptives. Because of this heightened vascular risk, migraines with aura are considered a contraindication to estrogen-based contraceptives, and alternative methods should be recommended.
C. BMI of 26: A body mass index in the overweight range does not constitute a contraindication to oral contraceptives. While efficacy may be slightly reduced in higher BMI individuals, oral contraceptives are generally safe and can be used with routine monitoring.
D. History of cholecystectomy: Removal of the gallbladder does not prevent safe use of oral contraceptives. Although estrogen can affect bile composition, past cholecystectomy does not increase the risk of serious complications from oral contraceptive therapy.
Correct Answer is D
Explanation
A. Administer bupropion 1 hr before meals: Bupropion is contraindicated in clients with bulimia nervosa due to an increased risk of seizures. Antidepressants such as SSRIs, like fluoxetine, are preferred for managing bulimia and comorbid depression.
B. Allow the client access to food throughout the day: Unrestricted access to food can trigger binge-eating episodes in clients with bulimia nervosa. Structured meal planning with scheduled eating times is more effective in reducing binge-purge behaviors.
C. Weigh the client once weekly: Weekly weighing is insufficient for monitoring rapid weight fluctuations associated with bulimia. Daily or more frequent monitoring, combined with close observation, is recommended to identify sudden changes and ensure safety.
D. Observe the client for 1 hr after meals: Post-meal observation helps prevent purging behaviors, such as self-induced vomiting or misuse of laxatives. This intervention directly addresses the core pathology of bulimia nervosa and supports safety and behavioral modification strategies.
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