A 60-year-old individual strays from a football game during halftime and is discovered 48 hours later, sleeping on a park bench 100 miles away.

The individual is brought to the emergency department by the police.

The individual can state their name and address but has no memory of the past 2 days. What is the priority nursing action?

Monitor mental status.

Encourage the individual to recall recent events.

Assess vital signs.

Contact family members.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Monitoring mental status is important, but it is not the priority nursing action in this situation. The individual has been found after being missing for 48 hours and the immediate concern should be their physical well-being.
Choice B rationale
Encouraging the individual to recall recent events may be part of the assessment process, but it is not the priority nursing action. The individual’s physical health could be at risk after being outside for an extended period, and this should be addressed first.
Choice C rationale
Assessing vital signs is the priority nursing action. The individual has been found after being missing for 48 hours, potentially exposed to harsh weather conditions and without access to food or water. It is crucial to assess their physical state as they may be dehydrated, hypothermic, or have other immediate health concerns.
Choice D rationale
Contacting family members is important for providing information and support, but it is not the priority nursing action. The first concern should be to assess and stabilize the individual’s physical condition.

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Correct Answer is A

Explanation

Choice A rationale
The statement “Why did you get so angry when she ignored you?” indicates a need for further training in effective therapeutic communication techniques. Asking “why” can make patients defensive and is generally avoided in therapeutic communication.
Choice B rationale
The statement “It is doubtful the president is out to get you” is a reality-oriented response and can be appropriate in certain contexts, such as when a patient is experiencing delusions.
Choice C rationale
The statement “Tell me more about the day your child died” invites the patient to share more about their experiences and feelings, which is a key aspect of therapeutic communication.
Choice D rationale
The statement “I don’t understand what you mean. Can you give me an example?” is an appropriate therapeutic communication technique, as it seeks to clarify the patient’s message.

A. Teach the client techniques for coping with the mother’s anger. B. Ask if the mother could come in for a hearing evaluation. C. Tell the client it appears the mother has a hearing loss. D. Inform the client to ignore the behavior and treat the mother with love.

Correct Answer is B

Explanation

Choice A rationale
While teaching the client techniques for coping with the mother’s anger might be helpful, it does not address the root cause of the problem. The mother’s anger and inappropriate responses could be due to frustration from not being able to hear properly.
Choice B rationale
The mother’s behavior of not responding when her back is turned and becoming increasingly angry could be signs of hearing loss. A hearing evaluation would help determine if this is the case and appropriate interventions can be put in place.
Choice C rationale
Telling the client that it appears the mother has a hearing loss is not the best intervention because it is based on assumption without any professional evaluation. It is important to have a professional evaluation before making such conclusions.
Choice D rationale
Informing the client to ignore the behavior and treat the mother with love does not address the potential issue of hearing loss. Ignoring the problem does not solve it and could lead to further frustration and misunderstanding.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a therapy session, which statement made by the nurse indicates a need for further training in effective therapeutic communication techniques?

Correct Answer is A

Explanation

A client reports to the nurse that her elderly mother has become increasingly angry and responds inappropriately to conversations within the past few months. She notes that her mother does not respond when the mother’s back is turned. What is the best intervention for the nurse?

Correct Answer is B

Explanation

The home health aide reports to the practical nurse that the client has been trying to give away possessions. When the nurse asks the client about this behavior, the client says, “With my spouse dead, there’s no reason for me to go on.”. What is the best priority response by the nurse?

During the assessment phase of the nursing process, data collection takes place. What methods does the nurse employ to gather data? (Select all that apply.)

True or False: Lability is characterized by a rapid change in emotions.

Haldol 2mg IM stat has been ordered for the agitated client. Haldol is available in 5mg/ml. How many ml’s will you administer?

A patient with a history of suicidal ideation is under observation. When is the patient at the highest risk for self-harm?

What expected outcomes should the nurse document for a client diagnosed with a depressive disorder? (Select all that apply)

An adult patient assaulted another patient and was subsequently restrained. One hour later, which statement by the restrained patient requires the nurse’s immediate attention?

A client who recently went through an upsetting divorce is threatening to commit suicide with a handgun. The client is voluntarily admitted to the psychiatric unit. Which of the following nursing diagnoses has the highest priority?