A nurse is receiving report on four clients at the beginning of the shift. Which of the following clients should the nurse check first?

A client who is hearing command hallucinations.

A client who is verbalizing ideas of reference.

A client who is using neologisms.

A client who is demonstrating clang associations.

Answer and Explanation

The Correct Answer is A

Choice A reason: A client who is hearing command hallucinations should be prioritized first because command hallucinations can be particularly dangerous. These hallucinations can involve voices instructing the client to harm themselves or others. Immediate assessment and intervention are crucial to ensure the client's safety and to prevent potential harm. The nurse needs to address the client's safety concerns and implement necessary precautions.

Choice B reason: A client verbalizing ideas of reference, which involve misinterpreting events or remarks as having personal significance, may experience distress and paranoia. While these symptoms require attention and management, they do not typically pose an immediate risk to the client's or others' safety. The nurse should monitor and support the client but prioritize more urgent safety concerns first.

Choice C reason: A client using neologisms, or creating new words that are not understood by others, indicates a thought disorder. While this is a significant symptom that requires intervention, it does not typically pose an immediate risk to safety. The nurse should evaluate the client's communication and thought processes and provide appropriate care.

Choice D reason: A client demonstrating clang associations, which involve linking words based on sound rather than meaning, also indicates a thought disorder. This symptom requires attention, but it does not usually pose an immediate threat to the client's or others' safety. The nurse should assess the client's condition and provide appropriate interventions but prioritize more urgent safety concerns first.

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Correct Answer is B

Explanation

Choice A reason: Delirium is characterized by an acute onset, typically developing over hours to a few days. It is a sudden change in mental status that differs from conditions like dementia, which have a gradual onset. Therefore, gradual onset is not a characteristic finding of delirium.

Choice B reason: Impaired judgment is a common finding in delirium. Clients with delirium often have fluctuating levels of consciousness, attention deficits, and disorganized thinking, all of which can contribute to poor judgment. This cognitive impairment can lead to unsafe behaviors and difficulty in making decisions.

Choice C reason: Difficulty swallowing, or dysphagia, is not typically associated with delirium. Dysphagia is more often related to neurological conditions such as stroke, Parkinson's disease, or other disorders affecting the muscles involved in swallowing. While clients with delirium may have various physical symptoms due to underlying causes, difficulty swallowing is not a direct symptom of delirium itself.

Choice D reason: Slowed, flat speech is not a typical finding in delirium. Clients with delirium may exhibit rapid, incoherent, or disorganized speech due to their altered mental state. Slowed, flat speech is more commonly seen in conditions like depression or certain types of dementia rather than in acute delirium.

A. "The client is just like my parent, who never could quit drinking." B. "The client needs to accept responsibility for their drinking." C. "The client asked me to go on a date." D. "The client shares their feelings openly during group therapy."

Correct Answer is A

Explanation

Choice A reason: This statement is an indication of countertransference because the nurse is projecting personal feelings and experiences onto the client. By comparing the client to their parent who struggled with drinking, the nurse may unconsciously treat the client differently based on unresolved emotions or past experiences. Countertransference can interfere with the nurse's ability to provide objective and compassionate care.

Choice B reason: This statement reflects a judgment about the client's responsibility for their drinking but does not indicate countertransference. While it is important for clients to take responsibility for their actions, this statement does not involve the nurse projecting their own feelings or experiences onto the client. It is more about the nurse's perspective on the client's behavior.

Choice C reason: This statement describes an inappropriate boundary violation by the client but does not indicate countertransference on the part of the nurse. The nurse should address the boundary issue professionally, but this situation does not involve the nurse's personal feelings or experiences influencing their perception of the client.

Choice D reason: This statement is a factual observation about the client's behavior during group therapy and does not indicate countertransference. It reflects the client's willingness to share their feelings, which is a positive aspect of their therapy process. There is no evidence of the nurse's personal feelings or experiences affecting their assessment of the client.

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A nurse is receiving report on four clients at the beginning of the shift. Which of the following clients should the nurse check first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has delirium. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is discussing the care of a client who has alcohol use disorder with another nurse. Which of the following statements should the nurse identify as an indication of countertransference?

Correct Answer is A

Explanation

A nurse is assisting with the plan of care for a client who has Alzheimer's disease. Which of the following actions should the nurse recommend implementing to assist the client with performing ADLs?

A nurse is collecting data from a client who reports cessation of nicotine use. Which of the following manifestations should the nurse expect? (Select all that apply.)

A nurse is caring for a client who has agreed to a verbal safety contract following a self-mutilation attempt. Which of the following behaviors indicates that the contract has been effective?

A nurse is collecting data from a client who experienced physical abuse as a child. Which of the following findings should the nurse identify as a risk factor for the client to become a perpetrator of child abuse?

A nurse is working with a group of clients during group therapy. For which of the following client disorders will setting limits serve as an appropriate behavioral management technique?

A nurse is reinforcing teaching with a client who has generalized anxiety disorder and a new prescription for buspirone. Which of the following information should the nurse include?

A nurse is caring for a client who has an anxiety disorder and reports ongoing difficulty sleeping at night. Which of the following recommendations should the nurse make?

A nurse is preparing to discharge a client who has depression. Which of the following information should the nurse plan to reinforce with the client regarding relapse?