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- Becoming isolated and withdrawn: While concerning, the risk is lower than active command hallucinations, making this a lower priority for immediate assessment.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 A
Explanation
A. A nurse tells a client's health care surrogate that the client might require restraints if diversion activities are ineffective: This does not meet the criteria for slander, as it involves a potential clinical plan of care rather than false statements.
B. A staff member reports to the unit supervisor during a private meeting that a coworker is possibly impaired: Communication during a private meeting does not constitute slander.
C. A nurse documents that a client was shouting and directly quotes the client's words: Documenting client behavior accurately in the medical record does not qualify as slander.
D. A client overhears an assistive personnel make a false statement about the assigned nurse and requests a different nurse: Slander involves making false verbal statements that harm someone's reputation. If overheard, this constitutes slander.
Correct Answer is ["B","D"]
Explanation
A. Teach a client about hemodialysis: This task requires an RN's advanced education and assessment skills.
B. Assist in checking a unit of packed RBCs to administer to a client: Assisting in double-checking blood products is within the scope of practice, although administration requires an RN.
C. Create a plan of care for a client's discharge: Developing a comprehensive discharge plan is a responsibility of the RN.
D. Regulate the client's infusion pump after initiating a heparin drip infusion: Once the heparin drip is initiated by an RN, LPNs can regulate the infusion pump.
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