A homeless male who was found sitting in the middle of a busy street is brought to the emergency department (ED). On admission, the client is confused and has difficulty answering questions. After ruling out a physiological etiology for the client's behavior, he is transferred to the mental health unit. When admitting the client to the unit, which action is most important for the nurse to take?

Ask the client about his recent substance use.

Perform a mental status exam.

Assess the client from head-to-toe.

Determine the number of previous hospitalizations.

Answer and Explanation

The Correct Answer is B

Choice A rationale: Asking the client about recent substance use is essential in assessing potential intoxication or withdrawal, which could contribute to the client's confused state. However, performing a mental status exam is the most important action to take.

Choice B rationale: The most important action for the nurse to take is to perform a mental status exam. This will help the nurse to assess the client's level of consciousness, orientation, memory, attention, mood, affect, thought process, and judgment. The mental status exam will also help the nurse to identify any signs of psychosis, delirium, dementia, or other mental disorders that may explain the client's behavior. Choice C rationale: Assessing the client from head-to-toe is a general nursing action but does not address the immediate need related to potential substance use. Choice D rationale: Determining the number of previous hospitalizations is relevant but does not address the current concern of substance use contributing to confusion.

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Correct Answer is B

Explanation

Choice A rationale: "Do you think someone is trying to harm you?" is a leading question and may contribute to the client's paranoid thoughts. It is important to explore the client's concerns without making assumptions.

Choice B rationale: "What makes you think people are stalking you?" is an open-ended question that invites the client to share more about her experiences and thought processes. It allows for a deeper exploration of the client's perceptions.

Choice C rationale: "It sounds like this experience is frightening for you" is a closed statement and may not encourage the client to elaborate on her thoughts. Open-ended questions are more effective in this situation.

Choice D rationale: "I know you are frightened, but no one is stalking you" is a dismissive statement that may invalidate the client's feelings. It is imp

A. Gastric lavage. B. Renal dialysis. C. Nebulizing with albuterol. D. Administration of naloxone.

Correct Answer is D

Explanation

Choice A rationale: Gastric lavage may be considered, but the priority is to address respiratory depression. Naloxone administration is more immediate.

Choice B rationale: Renal dialysis is not indicated for the overdose of methadone and benzodiazepines. Addressing respiratory depression is the priority.

Choice C rationale: Nebulizing with albuterol is not the appropriate intervention for respiratory depression due to drug overdose. Naloxone administration is more critical. Choice D rationale: Administration of naloxone is the priority for this client with respiratory depression due to the potential opioid overdose (methadone). Naloxone is an opioid antagonist that can reverse opioid-induced respiratory depression.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A middle-aged female client with no previous psychiatric history is seen in the mental health clinic because her family describes her as having paranoid thoughts. On assessment, she tells the nurse, "I want to find out why these people are stalking me!" Which response should the nurse provide?

Correct Answer is B

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?

Correct Answer is D

Explanation

A client with obsessive compulsive disorder (OCD) reports feeling "driven" to check the locks on the front door at least six times every night. Which response is best for the nurse to provide?

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 who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client's rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?

A client admitted to the mental health unit starts to shout and scream at the nurse. Which approach is best for the nurse to take?

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?

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 healthcare provider prescribes lithium carbonate for a client diagnosed with bipolar, manic depression. It is most important for the nurse to review which laboratory finding prior to beginning the drug therapy?