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

Answer and Explanation

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

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Correct Answer is C

Explanation

A. Changing the dressing is an action that comes after assessing and selecting the appropriate dressing. Before changing the dressing, the nurse needs to gather information and make decisions about the most suitable type of dressing based on the characteristics of the wound.

B. Selecting the appropriate dressing is an essential step, but before doing so, the nurse should review available dressing types to make an informed decision about which dressing will best meet the needs of the wound. This involves considering factors such as the wound's characteristics, exudate level, and the overall condition of the client.

C. Reviewing available dressing types is the first step because it allows the nurse to assess the wound, gather information about the client's condition, and make an informed decision about the most appropriate dressing. This step ensures that the chosen dressing aligns with the wound's characteristics and promotes optimal healing.

D. Documenting the dressing change is an important step in the process, but it typically occurs after the dressing change has been completed. Documentation is crucial for tracking the client's progress, ensuring continuity of care, and providing a record for other healthcare team members.

A. Complete an incident report about the occurrence. B. Check the client's vital signs. C. Notify the charge nurse of the error. D. Document the facts of the incident in the nurse's notes.

Correct Answer is B

Explanation

A. Completing an incident report is an important step to document the error, but the immediate priority is to assess the client's condition and address any potential adverse effects. Incident reporting can follow once the immediate assessment and interventions are completed.

B. Checking the client's vital signs is the first action to take. The nurse needs to assess the client's physiological response to the double dose, as some medications can have significant effects on vital signs. Monitoring vital signs provides crucial information to determine the client's stability and whether additional interventions are needed.

C. Notifying the charge nurse of the error is an important step, but checking the client's vital signs takes precedence to ensure the client's immediate safety. The charge nurse can be informed after the initial assessment.

D. Documenting the facts of the incident in the nurse's notes is important, but it comes after assessing the client and taking immediate actions to address any potential harm. Documenting the incident helps maintain a comprehensive record and contributes to the overall understanding of the event.

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A nurse on a mental health unit is caring for four clients. Which of the following clients should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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