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A nurse is caring for multiple clients on a mental health unit.
Which of the following clients should the nurse attend to first?.

A client who has bipolar disorder and is continuously pacing at the end of the hall.

A client who is standing in her room, yelling obscenities and throwing her clothes.

A client in the dayroom who is screaming at other clients about what is on the television.

A client who is repeatedly approaching the nurses' station to request medication for his anxiety.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

While pacing can indicate anxiety, this client is not currently a threat to themselves or others.

Choice B rationale:

This client is exhibiting aggressive behavior and could potentially harm themselves or damage property.

Choice C rationale:

Although this client’s behavior is disruptive, it is not immediately dangerous.

Choice D rationale:

This client’s repeated requests indicate anxiety, but they are not in immediate danger.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

Potential Provider Prescription	Expected or Unexpected?	Explanation
Administer acyclovir.	Unexpected	Acyclovir is an antiviral medication used to treat infections like herpes simplex virus (HSV) and varicella-zoster virus (VZV). The client’s confusion, agitation, and hallucinations do not suggest a viral infection as the primary cause.
Administer lorazepam.	Expected	Lorazepam is a benzodiazepine that can be used for acute agitation, anxiety, or delirium-related distress. Since the client is agitated and confused, lorazepam is an appropriate intervention.
Initiate 1:1 supervision.	Expected	The client is confused, agitated, and hallucinating, which increases the risk of self-harm, wandering, or injury. 1:1 supervision ensures safety.
Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion.	Expected	The client has dry mucous membranes, suggesting possible dehydration, which can contribute to confusion and agitation. IV fluids help restore hydration.

A. Use light restraints while the client is in bed. B. Place a lock at the top of doors leading outside. C. Encourage the client to nap during the day. D. Administer an antianxiety medication before bedtime.

Correct Answer is B

Explanation

Choice A rationale:

Using restraints can lead to injury and is generally a last resort.

Choice B rationale:

Placing a lock at the top of doors can prevent the client from wandering outside and getting lost or injured.

Choice C rationale:

Encouraging napping during the day can actually disrupt the client’s sleep cycle and increase nighttime wakefulness.

Choice D rationale:

While medication can be helpful, non-pharmacological interventions should be tried first.

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A nurse is caring for multiple clients on a mental health unit. Which of the following clients should the nurse attend to first?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has reviewed the nurses' notes, provider's note, and vital signs at 0400. Exhibits For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

A nurse is reinforcing teaching with the caregiver of a client who has Alzheimer's disease. The caregiver reports that the client awakens at night and wanders. Which of the following strategies should the nurse suggest?.

Correct Answer is B

Explanation

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A nurse is providing information to a client about smoking cessation. Which of the following medications should the nurse include?.

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A nurse is caring for a client who has depressive disorder following the recent death of their partner. Which of the following responses should the nurse make?.

A nurse is caring for a client who is experiencing a situational crisis. Which of the following actions should the nurse take first?.

A nurse is contributing to the plan of care for a client who has acute delirium. Which of the following interventions should the nurse include in the plan of care? .

A nurse is reinforcing teaching with a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?.

A nurse is caring for multiple clients on a mental health unit.
Which of the following clients should the nurse attend to first?.