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 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.

A. Ask the client to make a verbal contract to not harm self. B. Return the client to the waiting room with the spouse. C. Document that the client is not currently suicidal. D. Place the client in an ideal situation with one-on-one observation.

Correct Answer is D

Explanation

Choice A rationale
Asking the client to make a verbal contract to not harm themselves is a common strategy used in suicide prevention. However, it is not the primary responsibility of the practical nurse in this scenario.
Choice B rationale
Returning the client to the waiting room with the spouse is not the most appropriate action. The client’s safety is the top priority, and they should be closely monitored due to their erratic behavior and expressions of despair.
Choice C rationale
Documenting that the client is not currently suicidal is important, but it is not the primary responsibility of the practical nurse in this scenario. The client’s non-verbal cues (shrugging their shoulders) suggest they may be at risk.
Choice D rationale
The primary responsibility of the practical nurse in this scenario would be to place the client in an ideal situation with one-on-one observation. This ensures the client’s safety and allows for immediate intervention if necessary.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is D

Explanation

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 patient has been admitted due to severe depression. What symptoms should the nurse anticipate during the assessment?

During the mental status examination, the nurse observes that the client rapidly shifts from one idea to another related thought. Which disordered thinking process is the client displaying?

A patient inquires why they need to attend therapy and can’t just take their prescribed antidepressant medication. What would be the best explanation from the nurse?

A score of 1 to 10 on the Global Assessment Functioning (GAF) scale would indicate that a client was at risk for:

True or False: The management of delirium is dependent on its cause, with the primary focus being to address the root cause.

A patient with cognitive impairment, who has been a widow for 30 years, is desperately trying to leave the facility, stating, “I have to go home to cook dinner before my husband gets home from work.”. How should the nurse intervene using validation therapy?