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
A. While observing the client's condition is important, if the condition requires intervention, the nurse should prioritize notifying the healthcare provider first to ensure timely assessment and intervention.
B. Completing an incident report may be necessary if an error or adverse event occurs, but it should not be the first action when a client's condition requires immediate intervention.
C. Informing the nursing supervisor may be appropriate depending on the facility's policies, but the priority is to notify the healthcare provider who can directly address the client's condition.
D. Notifying the provider is the correct first action as they are responsible for the client's care and can provide further orders or instructions based on the situation.
Correct Answer is C
Explanation
A. Obtains client intake and output instead of delegating the task to an assistive personnel: While it may demonstrate initiative, effective time management involves delegating appropriate tasks to assistive personnel to maximize efficiency.
B. Skips lunch to catch up on client documentation: Skipping meals is not a sustainable or healthy time management strategy and may indicate poor self-care practices.
C. Reviews a client's medical record before performing a prescribed dressing change: This is the correct answer. Reviewing the client's medical record before performing a procedure ensures that the nurse is well-prepared and can perform the task efficiently and safely.
D. Documents medications administered throughout the shift at the end of the day: Documenting medications at the end of the day may lead to inaccuracies and delays in care. Timely and accurate documentation is essential for effective patient care.
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