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- Becoming isolated and withdrawn: While concerning, the risk is lower than active command hallucinations, making this a lower priority for immediate assessment.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. AU (both ears): This abbreviation is not recommended because it can be misinterpreted as referring to the eyes (OU) or ears (AU). The Joint Commission discourages using abbreviations that can lead to errors.
B. ADL (activities of daily living): This is a widely accepted and standardized abbreviation in healthcare documentation. It is not prone to misinterpretation.
C. HS (hour of sleep): HS can be misinterpreted as "half-strength." Therefore, it is not recommended for use in documentation according to best practice guidelines.
D. SQ (subcutaneous): SQ can be misread as "SL" (sublingual) or mistaken for "5 every." The recommended abbreviation is "subcut" or "subcutaneous."
Correct Answer is ["B","C","D"]
Explanation
A. Client 1: Worsening of the pressure injury with purulent drainage indicates infection and failure of pressure injury prevention strategies.
B. Client 5: The stage 3 pressure injury reduced in size and severity to stage 2, with the absence of purulent drainage, indicating wound healing and effective intervention.
C. Client 2: WBC count decreased from 11,500/mm³ to within the normal range at 9,500/mm³, indicating improvement in pneumonia.
D. Client 3: Temperature reduced from 38.9°C to 38°C, with stabilization of vital signs, suggesting improvement in the wound infection.
E. Client 4: An increase in WBCs in the urine from 2 to 6 per low-power field suggests worsening of the urinary tract infection, indicating program ineffectiveness.
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