The nurse is admitting a client who has not slept in three days to the inpatient care facility. The client has pressured speech and describes an increase in sexual promiscuity. Which problem should the nurse include in the client's plan of care?

Disturbed personal identity.

Risk for injury.

Ineffective coping.

Anxiety, panic.

Answer and Explanation

The Correct Answer is B

A) Disturbed personal identity could be relevant in the context of a mental health issue, but it is not the most immediate concern given the client's current presentation. While it may be important to address over time, it does not take precedence in the acute phase.

B) Risk for injury is the most critical problem to include in the client's plan of care. The client's lack of sleep, pressured speech, and increase in sexual promiscuity indicate a potential manic episode, which can lead to impulsive and unsafe behaviors. Prioritizing the risk for injury ensures the safety of the client and others, making it essential for the immediate care plan.

C) Ineffective coping is a concern that may develop in response to the client's current symptoms. However, addressing immediate safety needs is more urgent than focusing on coping mechanisms at this point.

D) Anxiety and panic might be present, but they are not as clearly defined in the client's current symptoms as the risk for injury. The focus should remain on preventing harm and ensuring the client is safe during this acute episode.

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Correct Answer is C

Explanation

A) Listening to what the client is saying can be important for understanding their perspective, but in this situation, the client's loud and wild behavior may be disruptive or alarming to others. Prioritizing safety is crucial.

B) Sitting in the chair next to the client could help establish rapport, but it does not address the immediate need to manage the disruptive behavior. The nurse must first ensure a safe environment for all clients.

C) Escorting the client to his room is the best initial action. This intervention helps to remove the client from the potentially stimulating environment of the day room, reducing the likelihood of escalation and providing a quieter space where the client can feel more secure and calm. It also minimizes disruption to other clients.

D) Administering a PRN sedative may be necessary if the behavior continues to escalate, but it should not be the first action taken. Non-pharmacological interventions, such as providing a safe space, should be prioritized before considering medication.

A. Explains answers to open-ended questions. B. Reports enjoyment from assigned activities. C. Shares a personal story with peers. D. Performs activities of daily living.

Correct Answer is D

Explanation

(A) Explains answers to open-ended questions:While explaining answers to open-ended questions indicates cognitive engagement, it does not directly address avolition, which is characterized by a lack of motivation to perform purposeful activities.

(B) Reports enjoyment from assigned activities:Reporting enjoyment from activities is a positive sign, but it does not necessarily indicate an improvement in the motivation to initiate and complete tasks independently.

(C) Shares a personal story with peers:Sharing personal stories can demonstrate social engagement, but it does not directly reflect an improvement in avolition, which involves the motivation to perform daily tasks.

(D) Performs activities of daily living:Performing activities of daily living (ADLs) demonstrates an improvement in avolition, as it shows the client is motivated to take care of themselves and engage in necessary daily tasks. This behavior directly aligns with the goal of improving avolition.

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The nurse is admitting a client who has not slept in three days to the inpatient care facility. The client has pressured speech and describes an increase in sexual promiscuity. Which problem should the nurse include in the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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 C

Explanation

The mental health team working with a homeless client with chronic schizophrenia establishes the treatment goal of, "Improvement in avolition prior to discharge." Which behavior demonstrates achievement of this goal to the nurse?

Correct Answer is D

Explanation

A female client admitted to the mental health unit starts to shout and scream at the nurse. Which is the best approach for the nurse to take?

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