An adult client presents to the community mental health center accompanied by the client’s spouse who reports that the client has been acting impulsively. The client has spent a large amount of money lately, made several last-minute decisions to take trips, sleeps only 2 to 4 hours a night, and has lost 33 pounds (15 kg) in the last 2 months. Which nursing problem has the greatest nursing priority?

Sleep deprivation related to state of hyperactivity.

Ineffective coping related to biochemical changes.

Risk for self-directed violence related to impulsive behavior.

Imbalanced nutrition related to caloric expenditure.

Answer and Explanation

The Correct Answer is C

A.   While sleep deprivation is a concern, the client's impulsive behavior poses a greater immediate risk, making "Risk for self-directed violence related to impulsive behavior" the priority.
B.   Ineffective coping may be a contributing factor, but the risk of self-directed violence takes precedence as the primary concern.
C. The client's impulsive behavior increases the risk of self-directed violence, making it the most urgent nursing priority.
D.   Imbalanced nutrition is a concern, but the immediate risk of self-directed violence requires more immediate attention.

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Correct Answer is A

Explanation

A. Advising the mother to call the police if violent behavior occurs again addresses the safety of the client and others and is a necessary step to ensure appropriate intervention.
B. Referring the mother for psychiatric evaluation is important but may not directly address the immediate safety concern related to the recent violent behavior.
C. Reinforcing the need for the adolescent to attend group therapy sessions is relevant, but the immediate focus should be on addressing the safety issue.
D. Telling the mother to describe her feelings may be helpful for therapeutic communication but may not be the most urgent intervention in response to the reported violent behavior.

A. A summary of the client’s feelings B. The client’s significant other’s statement C. A general description D. Photographs

Correct Answer is D

Explanation

A. Documenting the client’s feelings is important but may not provide objective evidence of injuries.
B. The significant other’s statement may be biased and may not accurately represent the client's injuries.
C. A general description may lack specificity, making it difficult to convey the extent and nature of the injuries.
D. Photographs are objective and provide visual documentation of the injuries, offering a clear and accurate record for legal and healthcare purposes.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse completes an assessment of a client experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?

Correct Answer is D

Explanation

An adolescent who is a heroin addict is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?

The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?

A client with post-traumatic stress disorder (PTSD) is experiencing a dissociative disorder episode. The situation quickly escalates, and the client becomes physically aggressive. Which intervention should the nurse implement first?

The nurse is leading a group on the inpatient psychiatric unit. Which approach should the nurse use during the working phase of group development?

Which individual should the nurse consider at the highest risk for suicide?

Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?

A male client with schizophrenia continues to talk to others on the mental health unit using tangential speech. What intervention should the nurse implement?