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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  • Becoming isolated and withdrawn: While concerning, the risk is lower than active command hallucinations, making this a lower priority for immediate assessment.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 D

Explanation

A. Tell the client's partner the charge nurse can provide the results: The charge nurse would still be bound by HIPAA regulations and cannot share the client's information without consent.
B. Tell the client's partner the results of the laboratory tests: Sharing health information without the client’s permission violates HIPAA regulations.
C. Tell the client's partner not to worry about the results: This response dismisses the partner's concerns and does not address the privacy issue.
D. Tell the client's partner to ask the client about the results: This is the appropriate action, as the client has the right to choose whom to share their health information with.

Correct Answer is B

Explanation

A. A client who has pneumonia and is receiving 100% oxygen via a non-rebreather mask: This client requires intensive respiratory care and cannot be safely discharged.
B. A client who has ascites and had a paracentesis 4 hr ago: This client is stable following a low-risk outpatient procedure and can be safely managed at home.
C. A client who has a blood glucose level of 380 mg/dL and is receiving insulin via IV infusion: This client has poorly controlled hyperglycemia requiring close monitoring and treatment.
D. A client who is 6 hr postoperative following a hip arthroplasty: This client requires postoperative monitoring and pain management and is at risk for complications.

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