A nurse on an in-patient unit received report at 15:00 hours. Which client should the nurse see first?

A client diagnosed I with hypomania who is speaking loudly on the unit.

A client diagnosed with hypomania who is complaining of pain.

A client with a history of mania who is pacing in the hallway

A client diagnosed with mania who expressed active suicidal ideations

Answer and Explanation

The Correct Answer is D

A. A client diagnosed with hypomania who is speaking loudly on the unit: Hypomania involves elevated mood and increased activity, but it doesn't typically present an immediate risk of harm to self or others. While it may be disruptive, it doesn't have the same urgency as active suicidal ideation.

B. A client diagnosed with hypomania who is complaining of pain: Pain complaints should be addressed, but in the context of the given choices, it is not the highest priority. Assessing and addressing the potential for harm due to active suicidal ideation is more critical.

C. A client with a history of mania who is pacing in the hallway: Pacing in the hallway, while indicative of increased activity, does not necessarily indicate an immediate risk. The client expressing active suicidal ideations poses a more urgent concern that requires immediate attention.

D.A client diagnosed with mania who expressed active suicidal ideations

In determining priority, the nurse should consider the level of risk and the potential for harm to self or others. Suicidal ideation is a significant concern that requires immediate attention. A client expressing active suicidal thoughts poses an immediate risk to their safety.

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Correct Answer is D

Explanation

A. Limit time for the client to perform activities:

This option may increase agitation and frustration for the client with Alzheimer's disease. It is generally not recommended to limit their time for activities, as it may lead to distress.

B. Rotate assignment of daily caregivers:

Consistency in caregivers is often beneficial for individuals with Alzheimer's disease. Constantly changing caregivers can lead to confusion and anxiety for the client. Thus, rotating caregivers is not the best approach.

C. Provide an activity schedule that changes from day to day:

Individuals with Alzheimer's disease often benefit from routine and predictability. Changing the activity schedule daily can cause confusion and disorientation. Therefore, it is not the most appropriate intervention.

D. Talk the client through tasks one step at a time:

This is the best choice because breaking down tasks into simple, manageable steps can help individuals with Alzheimer's disease understand and follow instructions. It promotes a sense of accomplishment and reduces frustration. This approach is aligned with the principles of dementia care.

A. The voices are telling me to harm myself B. I hear Voices C. I see birds flying in the room D. The voices don't stop and continue all day

Correct Answer is A

Explanation

A. The voices are telling me to harm myself: This statement indicates command hallucinations with a potential for harm. It suggests that the patient is receiving directives to harm themselves, which poses an immediate safety concern. Implementing safety measures, such as close monitoring, removal of harmful objects, and involving appropriate professionals, is essential to protect the patient from self-harm.

B. I hear voices: While hearing voices (auditory hallucinations) is a symptom that requires assessment and intervention, the nature of the voices is crucial in determining the level of risk. This statement, on its own, does not provide information about the content or potential harm associated with the voices.

C. I see birds flying in the room: This statement describes a visual hallucination, which, while potentially distressing, does not necessarily pose an immediate safety risk to the patient or others. Visual hallucinations may be less likely to necessitate immediate safety measures compared to command hallucinations.

D. The voices don't stop and continue all day: This statement suggests persistent auditory hallucinations, but without information about the content of the voices, it does not specifically indicate a risk of harm. While it may be distressing for the patient, the urgency for safety measures depends on the nature of the auditory content.

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A nurse on an in-patient unit received report at 15:00 hours. Which client should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Correct Answer is D

Explanation

Which hallucination necessitates the nurse to implement safety measures? The patient says.

Correct Answer is A

Explanation

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