A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determine the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?

Ineffective community coping.

B Disturbed sensory perception.

Self-care deficit.

Acute confusion.

Answer and Explanation

The Correct Answer is D

A.   Ineffective community coping may be a concern for a homeless individual but is not the priority in this scenario where the client is disoriented and confused.
B.   Disturbed sensory perception typically involves alterations in visual, auditory, tactile, or olfactory senses, which may not be the primary issue in this case.
C.   While self-care deficit could be a concern for a homeless individual, it is not the priority when the client is disoriented, disorganized, and confused.
D.   Acute confusion is the priority problem because the client is disoriented, disorganized, and confused, indicating a cognitive impairment that needs immediate attention. E. There is no specific rationale provided for this option.

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Correct Answer is A

Explanation

Rationale:
A. MAO inhibitors such as phenelzine can cause significant fluctuations in blood pressure, including hypertensive crisis when combined with certain foods or medications. Therefore, monitoring blood pressure is crucial to detect and prevent hypertensive emergencies.
B. While monitoring urinary output is important for overall assessment, it is not specifically associated with the use of MAO inhibitors like phenelzine.
C. Respiratory rate is not typically affected by MAO inhibitors like phenelzine and may not be the most relevant assessment finding in this scenario.
D. Temperature monitoring is important for general assessment but is not specifically associated with the use of MAO inhibitors like phenelzine.

A. Ask the client to describe and identify the source of the feelings. B. Provide education about ways to cope with anxiety. C. Assist the client with relaxation techniques in the group. D. Escort the client from the group to reduce stimuli.

Correct Answer is D

Explanation

A. Asking the client to describe and identify feelings is more appropriate for a client with mild to moderate anxiety, not severe anxiety.
B. Providing education is ineffective during severe anxiety because the client is unable to process new information.
C. Relaxation techniques are difficult for a client to use during severe anxiety due to impaired concentration and focus.
D. Reducing environmental stimuli by escorting the client from the group is the best intervention for severe anxiety, as it helps the client regain control and lowers anxiety levels.

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A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determine the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In conducting the initial assessment of a preoperative client, the nurse notes that the client's home medications include the monoamine oxidase (MAO) inhibitor phenelzine. Because of this client's medication history, which assessment finding is most important for the nurse to monitor?

Correct Answer is A

Explanation

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

Correct Answer is D

Explanation

The nurse has received a new prescription for the client to begin taking sertraline. Prior to administering the initial dose of sertraline, it is most important for the nurse to obtain which information?

The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessment?

The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

During a family group meeting, the client's daughter tells the group, "I hope I didn't cause Mom to be depressed." Which response is best for the nurse to provide?

The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Which is the best approach for the nurse to use when interviewing a client about suicidal ideations?

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?