A charge nurse on a mental health unit is receiving a change of shift report for a group of clients.
Complete the following sentence by using the lists of options.
The nurse should first collect data from
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- Becoming isolated and withdrawn: While concerning, the risk is lower than active command hallucinations, making this a lower priority for immediate assessment.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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Asking a staff member from another unit to complete the evaluation: Staff from other units may not have direct knowledge of the nurse's work performance.
B. Linking the evaluation to predetermined standards: Using predetermined standards ensures objectivity and consistency in evaluations.
C. Focusing primarily on areas that need improvement: Evaluations should be balanced, recognizing both strengths and areas for improvement.
D. Discussing the evaluation with the nurse manager: The evaluation should first be completed independently before discussing it with a manager if needed.
Correct Answer is B
Explanation
A. Report the incident to the charge nurse: Reporting is important but not the immediate priority to address the privacy breach.
B. Log the previous user out of the system: Securing the information immediately prevents further unauthorized access, making this the priority action.
C. Offer to conduct a unit in-service on client confidentiality: Education is beneficial but is not the immediate priority.
D. Complete an incident report: Documentation is essential but should occur after the situation is resolved.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.