The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention?
A 16-year-old client diagnosed with major depression who refuses to participate in group.
A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby.
An 18-year-old client with antisocial behavior who is being yelled at by other clients.
A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack.
None
None
The Correct Answer is B
Choice A reason: A 16-year-old client diagnosed with major depression who refuses to participate in group does not require the nurse's immediate attention. Depression is a mood disorder that causes persistent feelings of sadness, hopelessness, and loss of interest. Refusing to participate in group may indicate low motivation, social withdrawal, or poor self-esteem, which are common symptoms of depression. The nurse should respect the client's preference and offer alternative activities or individual therapy.
Choice B reason: This client requires immediate intervention because pacing can be a sign of agitation, restlessness, or escalating mania. Clients with bipolar disorder in a manic phase may exhibit increased energy, impulsivity, irritability, and even aggression. If not addressed promptly, this behavior could escalate to disruptive outbursts, impulsive actions, or even violence toward themselves or others. The nurse should intervene by using calm communication, redirection, and possibly medication if prescribed to help de-escalate the situation and ensure safety.
Choice C reason: This scenario involves peer conflict, which is important to address, but it does not necessarily indicate an immediate risk of harm. Clients with antisocial behavior often engage in conflict due to manipulative or confrontational tendencies, but being yelled at does not mean they are in immediate danger. The nurse should monitor the situation and intervene to prevent escalation, but other safety concerns take priority.
Choice D reason: A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack does not require the nurse's immediate attention. Anorexia nervosa is an eating disorder that causes extreme restriction of food intake and fear of weight gain. Refusing to eat the evening snack may indicate distorted body image, dietary rules, or anxiety, which are common factors of anorexia nervosa. The nurse should encourage the client to eat and provide support and education.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D is correct because frequent exposure to sunlight is the most significant environmental factor when planning care for a client with osteomalacia. Osteomalacia is a condition in which the bones become soft and weak due to inadequate mineralization, often caused by vitamin D deficiency. Vitamin D is essential for calcium absorption and bone health, and it can be synthesized by the skin when exposed to sunlight. The nurse should encourage the client to get at least 15 minutes of sunlight per day or take vitamin D supplements as prescribed.
Choice A is incorrect because quiet, calm surroundings are not a specific environmental factor for a client with osteomalacia. Quiet, calm surroundings may help reduce stress and promote relaxation, but they do not affect bone mineralization or vitamin D synthesis.
Choice B is incorrect because stimulating sounds and activity are not a specific environmental factor for a client with osteomalacia. Stimulating sounds and activity may help improve mood and cognition, but they do not affect bone mineralization or vitamin D synthesis.
Choice C is incorrect because cool, moist air is not a specific environmental factor for a client with osteomalacia. Cool, moist air may help relieve respiratory symptoms or allergies, but it does not affect bone mineralization or vitamin D synthesis.
Correct Answer is B
Explanation
Choice A: Ask for a consultation with a psychologist. This is not the best intervention, as it does not address the physical aspect of pain management. A psychologist may help the client cope with emotional distress and cognitive-behavioral strategies to reduce pain perception, but it may not be enough to relieve severe pain.
Choice B: Arrange an appointment with a pain specialist. This is the best intervention, as it addresses the physical aspect of pain management. A pain specialist may prescribe appropriate medications, perform interventional procedures, or recommend alternative therapies to relieve severe pain.
Choice C: Contact a hospice nurse for an evaluation. This is not the best intervention, as it does not address the eligibility criteria for hospice care. Hospice care is intended for clients who have a terminal illness with a life expectancy of six months or less, and who have decided to forego curative treatments. Fibromyalgia is not a terminal illness, and hospice care may not be appropriate for this client.
Choice D: Form an interdisciplinary team for evaluation. This is not the best intervention, as it does not address the urgency of pain management. An interdisciplinary team may consist of various healthcare professionals who can provide holistic care for the client, but it may take time to coordinate and implement their services.
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