A nurse on a mental health unit is caring for four clients. Which of the following clients should the nurse see first?
A client who has schizophrenia and exhibits apathy
A client who has an anxiety disorder and appears restless
A client who has major depressive disorder and reports hopelessness
A client who has bipolar disorder and exhibits provocative behavior
The Correct Answer is C
A. A client with schizophrenia exhibiting apathy may require attention, but it may not be an immediate priority unless there are signs of deterioration or safety concerns.
B. A client with an anxiety disorder appearing restless may be experiencing distress, but it is not necessarily indicative of an immediate safety or crisis situation.
C. A client with major depressive disorder reporting hopelessness raises significant concern, as it may indicate an increased risk of self-harm or suicide. Clients expressing hopelessness should be assessed promptly to determine the level of risk and implement appropriate interventions.
D. A client with bipolar disorder exhibiting provocative behavior may pose a potential risk, but the level of urgency is typically higher for a client expressing hopelessness and depressive
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Disinfect hands using an alcohol-based waterless antiseptic:
While alcohol-based hand sanitizers are effective against many germs, including bacteria, they may not be as effective against C. difficile. Soap and water are preferable for hand hygiene in C. difficile cases because alcohol does not effectively kill the spores.
B. Wear an N95 respirator when caring for the client:
The primary mode of transmission for C. difficile is through the fecal-oral route, and respiratory precautions are not necessary. Standard precautions, including wearing gloves and gowns, are generally sufficient.
C. Use diluted bleach to clean soiled equipment:
This is the correct answer. Bleach is an effective disinfectant against C. difficile spores. It is recommended for cleaning surfaces and equipment that may be contaminated.
D. Provide a room with negative-pressure airflow:
Negative-pressure airflow rooms are typically reserved for airborne infections, and they are not necessary for C. difficile. Standard precautions, along with thorough cleaning and disinfection, are the key measures.
Correct Answer is A
Explanation
Fidelity: Fidelity refers to the concept of keeping promises and being faithful to commitments made to individuals. In this scenario, when the nurse states they will return as soon as possible with pain medication, they are making a commitment to the client and demonstrating fidelity by keeping that promise.
Justice: Justice pertains to fairness and the equitable distribution of resources. It is not directly related to the nurse's commitment to providing pain medication.
Autonomy: Autonomy involves respecting the individual's right to make decisions about their own care. While informing the client about the plan for pain medication is part of communication, the primary ethical principle being demonstrated here is fidelity.
Nonmaleficence: Nonmaleficence is the principle of doing no harm. While it is important in healthcare, the scenario described focuses more on the nurse's commitment to providing pain relief.
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