A nurse on an inpatient mental health unit is caring for a client.

Exhibits

The nurse is discussing the assessment findings on day 3 of admission during the 1900 change of-shift report. For each finding, specify whether the finding indicates potential improvement in or worsening of the client’s condition.

Giving away car

Hygiene

Food intake

Condition of skin on right hand

Rapid change in mood

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Indicates potential Improvement a. Hygiene b. Food intake c. Rapid change in mood

Indicates potential worsening a. Giving away car b. Condition of skin on right hand

Choice A: Giving away car

This could be a sign of the client’s worsening condition. Giving away possessions can sometimes be a sign of suicidal ideation. It’s important to monitor this behavior and report it to the healthcare provider.

Choice B: Hygiene

The client showered without prompting on the third day, which is an improvement from the first day when they declined to shower. Improved personal hygiene can be a sign of improvement in a client with obsessive-compulsive disorder.

Choice C: Food intake

The client ate 75% of their meals on the third day, which is an improvement from the first day when they refused to eat. Increased food intake can indicate an improvement in the client’s condition2.

Choice D: Condition of skin on right hand

The client’s hands remain reddened with a 1 cm x 1 cm area of peeling skin noted on the center of the right palm. This could indicate a worsening condition, as it may be a result of excessive handwashing, a common compulsion in OCD.

Choice E: Rapid change in mood

The client’s affect rapidly changed throughout the afternoon and early evening; the client is now talkative and appears content. This could indicate an improvement in the client’s condition, as they are engaging more with others and showing more positive emotions.

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Correct Answer is C

Explanation

Choice A reason: While a unit secretary who speaks the same language could potentially communicate with the client, they may not be trained in medical terminology or confidentiality practices. Effective communication in healthcare settings requires more than just language proficiency; it involves understanding the nuances of medical dialogue and ensuring privacy and accuracy.

Choice B reason: Relying on another client for translation is not advisable. This could breach confidentiality, and the other client may not have the necessary skills to translate medical information accurately. Additionally, it places an undue burden on the client, who is there to receive support, not to provide services.

Choice C reason: A professional translator, preferably of the same gender as the client if it makes the client more comfortable, is the best option. Professional translators are trained to handle medical terminology and to navigate the cultural nuances that may arise in communication. They are also bound by confidentiality agreements to protect the client's privacy³.

Choice D reason: While a family member may be able to communicate effectively in the client's language, there are potential issues with privacy, accuracy, and dynamics that could affect the client's comfort and willingness to share openly in a support group setting. Family members may also unintentionally alter or withhold information based on their own biases or desires.

Correct Answer is ["1.4"]

Explanation

Step 1 is to identify the required dose, which is 7 mg of haloperidol.

Step 2 is to identify the concentration of the available haloperidol injection, which is 5 mg/mL.

Step 3 is to calculate the volume to be administered using the formula: Volume = Dose ÷ Concentration.

So, let's calculate:

Volume = 7 mg (Dose) ÷ 5 mg/mL (Concentration)

This gives us:

Volume = 1.4 mL

However, we need to round the answer to the nearest tenth and use a leading zero if it applies. So, the final volume to be administered is 1.4 mL. The nurse should administer 1.4 mL of haloperidol injection.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to lead a support group for clients who have alcohol use disorder. One of the group members is a client who speaks a different language than the nurse. Which of the following individuals should the nurse ask to assist with communication?

Correct Answer is C

Explanation

A nurse is preparing to administer 7 mg of haloperidol IM to a client who is severely agitated. Haloperidol injection of 5 mg/mL is available. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["1.4"]

Explanation

A nurse is caring for a client who has major depressive disorder and states that they have given away their personal belongings. Which of the following responses should the nurse make?

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