A nurse is reviewing the medical records of a group of clients. For which of the following clients should the nurse recommend a referral for assertive community treatment (ACT)?

A client who has a new diagnosis of major depressive disorder

A client who has repeated acute care admissions due to schizophrenia

A client who has requested family therapy following the death of a family member

A client who has physical injuries following an incident of partner violence

Answer and Explanation

The Correct Answer is B

A. A client who has a new diagnosis of major depressive disorder: While major depressive disorder can significantly impact functioning and may require treatment, it typically does not meet the criteria for ACT, which is primarily designed for individuals with severe and persistent mental illness.

B. A client who has repeated acute care admissions due to schizophrenia: Repeated acute care admissions due to schizophrenia suggest significant challenges in managing the illness and maintaining stability in the community. This client may benefit from the intensive support and comprehensive services provided by ACT to prevent future hospitalizations and promote community integration.

C. A client who has requested family therapy following the death of a family member: Family therapy may be an appropriate intervention for supporting this client's grieving process and addressing family dynamics. However, it does not necessarily indicate the need for ACT, which is focused on individuals with severe and persistent mental illness.

D. A client who has physical injuries following an incident of partner violence: While this client may require support and interventions to address the effects of partner violence, it does not specifically indicate the need for ACT unless there are underlying severe and persistent mental health issues contributing to the situation.

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Correct Answer is ["B","C","E"]

Explanation

A. Delirium often causes disorganized thinking and communication, but speech can be either slow or rapid and incoherent. Slow speech is not a definitive sign of delirium.

B.Rapid mood changes are commonly seen in delirium. Clients may exhibit sudden shifts in mood, such as becoming agitated, anxious, irritable, or euphoric, often without apparent cause.

C.Hallucinations, both visual and auditory, are common manifestations of delirium. Clients may perceive things that are not present, hear voices, or experience other sensory distortions.

D.Delirium typically involves an altered level of consciousness, which can range from hyperalertness to lethargy. An unaltered level of consciousness is not characteristic of delirium.

E.Restlessness, agitation, and an inability to sit still are frequent manifestations of delirium. Clients may exhibit hyperactivity, fidgeting, pacing, or attempting to remove medical devices or clothing.

A. The child has a history of jaw factures B. The child seems frightened of their parent C. The child has had no immunizations since birth D. The child rocks back and forth continually.

Correct Answer is C

Explanation

A. The child has a history of jaw fractures: This finding suggests physical abuse rather than neglect. Jaw fractures are not typically associated with neglect unless they result from untreated medical conditions or lack of appropriate supervision.

B. The child seems frightened of their parent: This finding may indicate emotional abuse or exposure to domestic violence rather than neglect. While fearfulness can be a sign of maltreatment, it does not specifically indicate neglect unless it is related to the failure of the parent to provide adequate care.

C. The child has had no immunizations since birth: This finding is indicative of medical neglect, which is a form of child neglect. Failure to provide necessary medical care, such as immunizations, can put the child at risk of preventable diseases and is considered a form of neglect.

D. The child rocks back and forth continually: This finding may suggest developmental delays or emotional distress but is not necessarily indicative of neglect on its own. However, if the rocking behavior is related to inadequate stimulation, supervision, or care from the caregiver, it could be considered a sign of neglect.

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A nurse is reviewing the medical records of a group of clients. For which of the following clients should the nurse recommend a referral for assertive community treatment (ACT)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has delirium as a result of sepsis. Which of the following manifestations should the nurse expect? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse is conducting a child maltreatment screening of a family who has a toddler. Which of the following findings should the nurse identify as an indicator of possible child neglect?

Correct Answer is C

Explanation

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A nurse is conducting an admission assessment for a client who is experiencing a manic episode of bipolar disorder. Which of the following behaviors should the nurse expect? (Select all that apply.)

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