An older adult male client with schizophrenia is found smearing feces on the bathroom walls of the chronic mental health unit where he resides. Which action should the nurse implement?

Show the client how to clean the walls.

Assist the client to clean the walls.

Escort the client out of the bathroom.

Explain that feces belong in the toilet.

Answer and Explanation

The Correct Answer is C

Choice A reason: Showing the client how to clean assumes cognitive capacity impaired in schizophrenia, where psychosis or disorganized thinking drives behaviors like fecal smearing. This may reflect delusions, not a lack of cleaning knowledge. Escorting the client out prioritizes hygiene and safety, allowing psychiatric assessment over teaching in an acute situation.

Choice B reason: Assisting with cleaning risks reinforcing the behavior and exposes both to pathogens like E. coli in feces. Schizophrenia may impair compliance or understanding. Escorting the client out ensures safety and hygiene, enabling evaluation of psychotic triggers, making this less appropriate than removing the client from the situation.

Choice C reason: Escorting the client out prevents further pathogen exposure, as feces carry infection risks (e.g., gastroenteritis). In schizophrenia, smearing may stem from psychosis, requiring psychiatric evaluation. This action ensures hygiene and safety, allowing assessment of underlying mental health issues, addressing the behavior’s root cause effectively.

Choice D reason: Explaining that feces belong in the toilet assumes rational understanding, impaired in schizophrenia due to disorganized thought or delusions. This behavior likely reflects psychosis. Escorting the client out prioritizes hygiene and safety, followed by psychiatric intervention, making explanation less effective than immediate removal from the contaminated area.

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Correct Answer is B

Explanation

Choice A reason: Memory issues from TBI traumatic brain injury warrant cognitive assessment, not CAGE, which screens for alcoholism. Daily drinking suggests potential misuse, requiring CAGE. Memory affects recall, not alcohol screening priority, per substance abuse and neurological assessment standards in nursing admission interviews.

Choice B reason: Daily social drinking raises suspicion for alcohol misuse, warranting the CAGE questionnaire to screen for dependence. CAGE assesses alcohol-related behaviors, critical for identifying alcoholism in clients with regular intake, per substance abuse screening and admission assessment protocols in nursing practice.

Choice C reason: Antidepressant medication use suggests depression, requiring mental health assessment, not CAGE, which is for alcohol misuse. Daily drinking indicates screening need. Antidepressants are unrelated to alcohol patterns, per psychiatric and substance abuse assessment standards in nursing care during admission.

Choice D reason: Sexual assault history trauma requires trauma-informed care, not CAGE, which screens for alcoholism. Daily drinking triggers alcohol misuse screening. Assault history addresses psychological needs, per trauma assessment and substance abuse screening protocols, but CAGE is specific to alcohol in nursing.

A. A client with pancreatitis who has a fasting glucose of 190 mg/dL (10.55 mmol/L) today and had 160 mg/dL (8.88 mmol/L) yesterday. B. A client with a gastrointestinal (GI) bleed who is receiving a blood transfusion and has a hemoglobin of 7.0 g/dL (4.34 mmol/L). C. A client with cancer who has an absolute neutrophil count (ANC) of less than 500/mm3 today and had 2,000/mm3 yesterday. D. A client with hepatitis who is jaundiced and has a bilirubin level that is 4 times the normal value.

Correct Answer is C

Explanation

Choice A reason: Elevated glucose (190 mg/dL) in pancreatitis needs monitoring but is less urgent than severe neutropenia (ANC <500/mm3), which risks life-threatening infections. Glucose can be managed with insulin, per diabetes and pancreatitis care protocols, but neutropenia requires immediate intervention.

Choice B reason: Hemoglobin of 7.0 g/dL in a GI bleed is critical but less immediate, as the client is receiving a transfusion. Neutropenia (ANC <500/mm3) poses an urgent infection risk, requiring isolation. Transfusion addresses anemia, per bleeding and hematology care standards.

Choice C reason: An ANC <500/mm3 indicates severe neutropenia, posing an immediate infection risk in cancer patients, requiring urgent isolation and antibiotics. This rapid drop from 2,000/mm3 demands priority intervention to prevent sepsis, per oncology and infection control protocols in nursing practice.

Choice D reason: Elevated bilirubin in hepatitis is concerning but less urgent than neutropenia (ANC <500/mm3), which risks sepsis. Jaundice requires monitoring and treatment, but severe infection risk takes precedence, per liver disease and critical care prioritization standards in nursing practice.

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An older adult male client with schizophrenia is found smearing feces on the bathroom walls of the chronic mental health unit where he resides. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client information indicates the need for the nurse to use the CAGE questionnaire during the admission interview?

Correct Answer is B

Explanation

Which client’s laboratory value requires immediate intervention by a nurse? Reference Range: Hemoglobin (Hgb) [14 to 18 g/dL (8.7 to 11.2 mmol/L)]; Fasting Blood Glucose [70 to 110 mg/dL (3.9 to 6.1 mmol/L)]; Neutrophils (ANC) [55 to 70%: 2,500 to 8,000/mm3 (2.5 to 5.8 x109/L)]

Correct Answer is C

Explanation

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