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 A

Explanation

Choice A reason: Clients who are involuntarily admitted to a psychiatric facility retain certain rights, including the right to refuse medications. This is an important part of patient autonomy and informed consent. Even though the client is involuntarily admitted, they must still be provided with information about their treatment options and have the right to make decisions about their medications unless there is a court order stating otherwise.

Choice B reason: This statement is incorrect because involuntary admission means that the client cannot leave the facility at any time. Involuntary admission is typically initiated because the client is unable to meet their own physical needs or poses a danger to themselves or others. Therefore, their ability to leave the facility is restricted until their condition improves or their admission status is reviewed and changed.

Choice C reason: This statement is misleading because the review of admission status for involuntary patients usually occurs much sooner than 90 days. Legal requirements and procedures for reviewing involuntary admission status vary by jurisdiction, but typically, initial reviews occur within a few days to weeks to ensure that the client's rights are protected and that continued hospitalization is necessary.

Choice D reason: This statement is incorrect. Involuntary admission does not automatically result in the appointment of a legal guardian. The process of appointing a legal guardian is separate and involves a legal proceeding where a court determines the need for guardianship. The involuntary admission process is primarily focused on the immediate care and safety of the client.

A. Use a quick-release tie to restrain the client. B. Renew the restraint prescription every 48 hr. C. Attach the restraints to the side rail of the client's bed. D. Maintain 1 fingerbreadth between the restraint and the client's skin.

Correct Answer is A

Explanation

Choice A reason: Using a quick-release tie for restraints ensures that the nurse can quickly and easily release the client in case of an emergency. Quick-release ties are designed to provide safety and convenience, allowing healthcare providers to promptly respond to the client's needs without compromising safety. This method reduces the risk of injury to both the client and the healthcare team.

Choice B reason: Restraint prescriptions typically need to be renewed more frequently than every 48 hours, often within 24 hours. The exact duration depends on the facility's policy and regulatory guidelines. Regular assessment of the need for restraints and timely renewal of the prescription ensure that restraints are used appropriately and only as long as necessary.

Choice C reason: Attaching restraints to the side rail of the client's bed is unsafe and inappropriate. Restraints should be attached to a non-movable part of the bed frame to prevent the client from injuring themselves if the side rail is moved. Securing restraints to a stable part of the bed ensures better control and reduces the risk of harm.

Choice D reason: While maintaining some space between the restraint and the client's skin is important to prevent circulation issues, the guideline typically suggests maintaining two fingers' breadth between the restraint and the client's skin, not one. This ensures adequate circulation and reduces the risk of injury or skin breakdown.

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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

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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