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 C

Explanation

A. Episodic intervals of pruritus (itching) may suggest a dermatological condition or irritation of the scalp, but they do not directly indicate that the hair loss is not disease-related.
B. Erythema (redness) of the localized lesions may suggest inflammation or irritation but does not necessarily indicate that the hair loss is not disease-related.

C. Ecchymotic blood accumulations (bruising) suggest trauma or repeated pulling at the hair, which is not typically associated with disease-related causes. This finding can indicate a behavioral issue, such as trichotillomania (a compulsive hair-pulling disorder), where physical damage to the scalp can result in bruising and bald patches. The presence of ecchymosis supports a mechanical, non-disease-related cause of hair loss.

D. Evidence of patches of lost hair alone does not confirm whether the hair loss is disease-related or non-disease-related. Patches of hair loss can occur with both behavioral conditions (e.g., trichotillomania) and diseases (e.g., alopecia areata, fungal infections).

A. Efforts to cut down, annoyance with questions, guilt, drinking as an "Eye-opener." B. Consumption, liver enzyme, gastrointestinal complaints and bleeding. C. Cancer screening results, anger, gastritis, daily alcohol intake. D. Minimizes drinking, frequently misses family events, guilt about drinking, amount of daily intake.

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.

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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

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease related?

Correct Answer is C

Explanation

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

A client with a history of alcoholism is admitted for detoxification. Based on treatment protocol, the nurse gives the client a dose of lorazepam 6 mg. Which additional prescription should the nurse administer immediately?

A male client with a recent diagnosis of bipolar disorder takes lithium carbonate daily. The client informed the school nurse of the desire to live away from home to attend college after graduating in one month. Which information is most important for the nurse to provide the client and his family?

The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?

A client engages in repeated checks of door and window locks and behavior that prevents the client from arriving on time and interfering with the ability to function effectively. Which action should the nurse take?

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