A client that is homeless, well-educated, and has chronic schizophrenia is admitted to the mental health unit when found by the police walking in the middle of the street. The client presents with a strong body odor, dirty clothes, and avolition. After a week of neuroleptic drug therapy, the client discusses with the nurse thoughts about bathing. Which statement suggests that the client is progressing?

I know that bathing helps prevent infectious diseases.

Others say I am dirty and smell badly, so I will bathe.

I will take a bath today as requested.

I feel good when I take care of myself.

Answer and Explanation

The Correct Answer is D

Choice A rationale: "I know that bathing helps prevent infectious diseases" is a factual statement but may not necessarily reflect progress in the client's overall functioning and engagement in self-care. It focuses on the practical aspect of bathing rather than the client's motivation and insight.

Choice B rationale: "Others say I am dirty and smell badly, so I will bathe" suggests an external motivation rather than intrinsic motivation. Progress is better indicated when the client expresses a personal desire to engage in self-care activities.

Choice C rationale: "I will take a bath today as requested" indicates compliance with external requests rather than an internal desire to care for oneself. It is essential to foster the client's intrinsic motivation for self-care.

Choice D rationale: "I feel good when I take care of myself" reflects an internal motivation and positive reinforcement associated with self-care. This statement suggests progress in the client's willingness to engage in personal hygiene activities.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale: Ineffective breathing pattern is the highest priority nursing problem. Aspiration of a caustic material can lead to respiratory compromise, and ensuring adequate oxygenation takes precedence.

Choice B rationale: Risk for injury is important, but respiratory concerns associated with aspiration take priority in this situation.

Choice C rationale: Ineffective coping is relevant but does not take precedence over addressing immediate physiological needs such as breathing.

Choice D rationale: Impaired comfort is important, but the priority is to ensure the client's respiratory status and address potential complications of caustic material aspiration.

A. Screen the client for domestic violence. B. Determine the client's risk for suicide. C. Ask client to state a chief complaint for admission. D. Obtain a baseline set of vital signs.

Correct Answer is D

Explanation

Choice A rationale: Screening the client for domestic violence requires a more comprehensive assessment and interpretation of findings, which is beyond the scope of practice for the UAP.

Choice B rationale: Determining the client's risk for suicide involves complex judgment and should be assessed by a licensed healthcare provider, not a UAP.

Choice C rationale: Asking the client to state a chief complaint for admission involves initial communication and assessment skills, which should be performed by licensed nursing staff.

Choice D rationale: Obtaining a baseline set of vital signs is a routine task that can be delegated to the UAP. It is a non-complex and standard part of the admission process.

View Question and Answer

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?

Correct Answer is A

Explanation

The nurse is completing an admission assessment for a client with a known history of depression and multiple, unexplained fractures. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)?

Correct Answer is D

Explanation

A client is admitted to the emergency department because of a possible overdose of methadone and benzodiazepines. The admission respiratory rate is 6 breaths/minute. Based on this finding, the nurse should prepare for which intervention?

The nurse is reviewing an intake mental health assessment with a client who is seeking services for depression. The client reports feeling dizzy, excessively tired, experiencing headaches, and back pain. Which symptom should the nurse suspect is related to the client's feelings of depression?

The nurse is planning the care for a client who is hospitalized with a bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? Select all that apply.

An 18-year-old client is brought to the emergency department with a suspected drug overdose. Which information is most important for the nurse to obtain from the family?

A client with opioid dependence makes a statement to the nurse about desiring to lead a healthier lifestyle by making changes in the next 2 weeks. How should the nurse respond?

A 16-year-old female client is admitted to the psychiatric unit and states that she is depressed and anxious. The client appears frail and is wearing baggy clothes. When it is time for lunch, the client states, "I can't eat, I'm already overweight." What is the best response by the nurse?

A client who is experiencing a severe level of anxiety and reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?