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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Free Nursing Study Resources

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.

A. "I will notify law enforcement within 2 hours if he cannot be found." B. "I will give his most recent photo to the police." C. "I will place a sliding bolt lock just above the doorknob." D. "I will ensure the bedroom is dark while he is sleeping at night."

Correct Answer is C

Explanation

Choice A reason: Notifying law enforcement within 2 hours if the person cannot be found is important, but immediate action is usually recommended in such cases. The sooner the authorities are alerted, the better the chances of locating the individual safely.

Choice B reason: Giving the most recent photo to the police is a proactive step in case the person goes missing. It can help law enforcement quickly disseminate the information and aid in the search. However, this is a reactive measure rather than a preventive one.

Choice C reason: Placing a sliding bolt lock just above the doorknob can prevent the individual from wandering, which is a common and dangerous issue in people with advanced Alzheimer's disease. This measure helps ensure the person's safety by preventing unsupervised exits from the home.

Choice D reason: Ensuring the bedroom is dark while the person is sleeping may not be advisable. Adequate night lighting is important for preventing falls if the person needs to get up during the night. A completely dark room can increase the risk of injury.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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 teaching the caregiver of a client who has advanced Alzheimer's disease about home safety. Which of the following statements by the caregiver indicates an understanding of the teaching?

Correct Answer is C

Explanation

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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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