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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
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.
Correct Answer is D
Explanation
A) Request backup from the staff:Requesting backup may be necessary if the situation escalates and the client poses a threat to themselves or others. However, it should not be the first action. The nurse should initially attempt to de-escalate the situation by addressing the client’s immediate needs and providing personal space.
B) Encourage the client to sit down:Encouraging the client to sit down might help reduce their agitation, but it could also be perceived as controlling or dismissive. The nurse should first focus on creating a safe environment by providing personal space and then assess the client’s willingness to sit down.
C) Stand in the doorway:Standing in the doorway can provide the nurse with a quick exit if needed, but it may also make the client feel trapped or cornered. It is important to maintain a non-threatening posture and ensure the client has enough space to feel comfortable.
D) Provide for personal space:Providing personal space is crucial in managing aggressive behaviors. It helps to reduce the client’s sense of threat and allows them to feel more in control. This approach can help de-escalate the situation and create a safer environment for both the client and the nurse.
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