A nurse on an acute mental health unit is assessing four clients. Which of the following clients is the highest priority?

A client who has dementia and exhibits aphasia

A client who has bipolar disorder and displays constant pacing

A client who has schizophrenia and uses neologisms

A client who has depressive disorder and has poor personal hygiene

Answer and Explanation

The Correct Answer is B

A.   A client who has dementia and exhibits aphasia: While aphasia can be concerning, it is not necessarily indicative of immediate risk to the client or others.
B.   A client who has bipolar disorder and displays constant pacing: This client is the highest priority because constant pacing may indicate agitation or escalating anxiety, which could lead to agitation or aggression and require immediate intervention to prevent harm to the client or others.
C.   A client who has schizophrenia and uses neologisms: Neologisms, although indicative of disorganized thinking, do not necessarily present an immediate safety concern compared to constant pacing.
D.   A client who has depressive disorder and has poor personal hygiene: While poor personal hygiene is important to address for the client's well-being, it may not present an immediate safety risk compared to the behaviors exhibited by the client in option B.

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Correct Answer is A

Explanation

A. Elevating the head of the client’s bed to 30° before inserting a nasogastric (NG) tube is incorrect. The proper position for NG tube insertion is typically with the client sitting upright at 45–90° to reduce the risk of aspiration and facilitate the passage of the tube through the esophagus. This action requires intervention by the charge nurse to correct the positioning.

B. Maintaining the chest tube collection device below the level of the insertion site when ambulating the client is correct. This positioning prevents backflow of drainage into the pleural space, which could lead to complications such as pneumothorax or infection. No intervention is needed for this action.

C. Assisting the client into a fetal position on their side in preparation for a lumbar puncture is correct. This position helps to widen the spaces between the vertebrae, allowing easier access to the spinal canal for the procedure. This action does not require intervention.

D. Assessing the client’s gag reflex following an esophagogastroduodenoscopy (EGD) is correct. After an EGD, the client’s gag reflex must return before allowing oral intake to prevent aspiration. This action does not require intervention.

A. Check to see if the medical record indicates the provider explained the procedure to the client. B. Explain the risks of the procedure to the client. C. Convey the client's request to the nurse who witnessed the consent. D. Notify the provider about the client's concerns.

Correct Answer is A

Explanation

A: Checking the medical record to ensure the provider explained the procedure is important for verifying that the client has been informed, but it does not address any immediate concerns the client may have just before the procedure.

B: Explaining the risks of the procedure is typically the responsibility of the provider, not the nurse. The nurse should ensure that the client understands the information provided by the provider, but not introduce new information.

C: Conveying the client's request to the nurse who witnessed the consent is not as direct or immediate as notifying the provider. It may delay addressing the client's concerns.

D: Notifying the provider about the client's concerns ensures that the client’s questions and anxieties are addressed directly by the person most qualified to provide detailed information and reassurance. This action helps to ensure the client is fully informed and comfortable before proceeding.

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A nurse on an acute mental health unit is assessing four clients. Which of the following clients is the highest priority?

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