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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Conversion disorder involves the manifestation of neurological symptoms without a neurological basis. Sudden blindness with no organic pathology is indicative of a conversion disorder.
B. Complaints of headache and back pain may have organic or psychogenic causes; it does not specifically point to conversion disorder.
C. Extreme anxiety about going outside may be indicative of various anxiety disorders but does not align with the symptoms of a conversion disorder.
D. Complaints of shortness of breath and diaphoresis may have various causes, including medical conditions. It does not specifically indicate a conversion disorder.
Correct Answer is C
Explanation
A. A family history of dementia may be relevant but is not typically associated with violent nightmares. Alcohol use is more directly related to this symptom.
B. Witness to an accident may be a traumatic experience, but it does not specifically address the symptom of violent nightmares.
C. Alcohol use can contribute to sleep disturbances, including nightmares. Exploring the client's alcohol use is essential in understanding the cause of the nightmares.
D. Inadequate diversional activity is a broad concept and may not be directly related to the specific symptom of violent nightmares.
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