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A charge nurse on a mental health unit is receiving a change of shift report for a group of clients.

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first collect data from

due to and.
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}

Client 1 (First Priority):

  • Experiencing command hallucinations: Command hallucinations are auditory hallucinations that instruct the client to harm themselves or others, posing an immediate safety concern.
  • Potential risk of self-harm: Persecutory delusions and statements indicating "the agents are watching" suggest escalating paranoia, increasing the risk of dangerous behaviors or impulsive self-protective actions. Immediate intervention is essential to prevent harm.

Client 2 (Lower Priority):

  • Stopped taking medication: Non-compliance with medication has led to severe depressive symptoms, including isolation, withdrawal, and psychomotor retardation.
  • Becoming isolated and withdrawn: While concerning, the risk is lower than active command hallucinations, making this a lower priority for immediate assessment. However, this client requires evaluation soon after Client 1.

Client 3 (Lowest Priority):

  • Low lithium level (0.7 mEq/L): This level is slightly below the therapeutic range (0.8 to 1.2 mEq/L) but not critically dangerous.
  • Increased risk of agitation and instability: The symptoms of agitation and poor sleep are concerning, but immediate safety threats are less imminent compared to command hallucinations.


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Related Questions

Correct Answer is C

Explanation

A. Carry bedridden clients to safety by lifting them onto your back: This is not a safe or recommended practice for evacuating bedridden clients.
B. Ask ambulatory clients to help to move clients in wheelchairs: Ambulatory clients should be prioritized for independent evacuation rather than being assigned caregiving tasks.
C. Place dry towels around the bases of doors: This can help to prevent smoke from entering the room and provide some protection while awaiting rescue.
D. Aim the extinguisher at the top of the fire: The correct action is to aim the extinguisher at the base of the fire, where the fuel source is.

Correct Answer is D

Explanation

A. Disinfect hands using an alcohol-based waterless antiseptic. Alcohol-based hand sanitizers are ineffective against C. difficile spores. Handwashing with soap and water is required.
B. Wear an N95 respirator when caring for the client. C. difficile requires contact precautions, not airborne precautions.
C. Provide a room with negative-pressure airflow. Negative-pressure rooms are used for airborne pathogens, not C. difficile.
D. Use diluted bleach to clean soiled equipment. Bleach is effective in killing C. difficile spores and should be used to disinfect contaminated surfaces.

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