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

A. The CAGE questionnaire focuses on four key aspects related to alcohol use: efforts to Cut down, Annoyance with questions about drinking, feelings of Guilt about drinking, and using alcohol as an "Eye-opener" in the morning. Exploring these aspects in depth can provide valuable information about the client's relationship with alcohol and potential problems.

B. While information about consumption, liver enzymes, and gastrointestinal complaints is important for assessing alcohol-related issues, these are not specifically addressed by the CAGE questionnaire.
C. Cancer screening results, anger, gastritis, and daily alcohol intake are relevant to assessing the client's overall health and alcohol use but are not directly related to the questions asked in the
CAGE questionnaire.
D. While information about minimizing drinking, missing family events, guilt about drinking, and daily alcohol intake may provide insight into the client's alcohol use, these aspects are not specifically addressed by the questions in the CAGE questionnaire.

A. Alert the assigned staff to closely monitor client and intervene as needed to reduce risk of selfmutilation. B. Provide the client time alone in the client's room to reduce external stimulation and promote relaxation. C. Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed. D. Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm.

Correct Answer is A

Explanation

A. The client's increased body tension and pacing indicate escalating distress and potential risk for self-harm. Alerting staff to closely monitor the client and intervene as needed is crucial to ensure the client's safety.
B. Providing time alone in the client's room may be appropriate in some situations but may not address the immediate risk of self-mutilation if the client is experiencing escalating distress. C. Giving firm, consistent expectations about self-mutilating behaviors is important for establishing boundaries, but it may not be sufficient to address the immediate risk of self-harm without additional monitoring and intervention.
D. Completing a thorough room search is important for safety but may not address the immediate risk of self-harm if the client is already exhibiting signs of distress and pacing in the hallway.

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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

The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in depth with the client based on this screening tool?

Correct Answer is A

Explanation

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?

Correct Answer is A

Explanation

The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?

The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?

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