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 B

Explanation

A. Instructing the client to reduce the volume of his voice may not be effective during a manic episode and could escalate the situation.
B. Accompanying the client to a quiet area of the unit provides a more supportive and calming environment, allowing the client to deescalate.
C. Encouraging the client to attend a support group is a positive intervention but may not be immediately effective during an agitated state.
D. Administering a PRN sedative by injection may be considered, but less restrictive interventions should be attempted first to promote a therapeutic environment.

A. Sit in the chair next to the client. B. Listen to what the client is saying. C. Escort the client to his room. D. Administer a PRN sedative.

Correct Answer is B

Explanation

A. Sitting in the chair next to the client may be a supportive action but does not address the immediate concern of the client's behavior.
B. Listening to what the client is saying is crucial to understand the content and nature of the auditory hallucinations, which can guide further interventions.
C. Escorting the client to his room may be necessary if the behavior poses a risk, but understanding the content of the hallucinations should precede immediate removal.
D. Administering a PRN sedative may be considered later based on the assessment, but understanding the nature of the hallucinations and the client's current state is the priority.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping both feet while pacing the hallway. Which action should the nurse take?

Correct Answer is B

Explanation

A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. Which action should the nurse implement first?

Correct Answer is B

Explanation

The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?

A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?

The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?

The nurse is caring for a client who has been the victim of intimate partner violence. During the interview, the nurse feels angry, embarrassed, and helpless. Which explanation best describes the cause of the nurse’s emotions?

A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client’s rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?