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
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 D
Explanation
- Rationale for A: Observing the client's condition is an ongoing assessment task and while it is important, it is not the immediate action to take when a change in condition is noted. The nurse has already noticed a change, and further observation should follow intervention, not precede it.
- Rationale for B: Completing an incident report is a task that is done after an adverse event or error has occurred and been addressed. It is not the first action to take when a client's condition requires intervention, as it does not directly address the client's immediate needs.
- Rationale for C: Informing the nursing supervisor is an appropriate step, but it is not the first action to take. The supervisor may assist in the situation, but the provider who can give medical orders should be notified first to address the client's condition promptly.
- Rationale for D: Notifying the provider is the correct first action because the provider can assess the situation, make medical decisions, and order immediate interventions. This is the most direct way to initiate the necessary medical response to the client's change in condition.
Correct Answer is C
Explanation
A. Review facility policies for taking scheduled breaks: While understanding facility policies is important, it may not directly address the reasons why the nurses are not taking their scheduled breaks. This step can be taken after understanding the underlying issues.
B. Discuss time management strategies with the nurses: While time management strategies may be helpful, it's essential to first understand why the nurses are not taking their breaks before discussing potential solutions.
C. Determine the reasons the nurses are not taking scheduled breaks: This is the correct answer.
Understanding the reasons behind the nurses' behavior is crucial for addressing the issue effectively. It could be due to workload, staffing issues, personal preferences, or other factors.
D. Provide coverage for the nurses' breaks: While providing coverage may be necessary in the short term, it does not address the underlying reasons why the nurses are not taking their breaks and may not be a sustainable solution. Understanding the root cause is essential for
implementing appropriate interventions.
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