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 A

Explanation

Choice A rationale:A. The drug that was ingested is the most important information because knowing the specific substance determines the course of treatment. For example, acetaminophen overdose requires administration of N-acetylcysteine, while opioid overdose requires naloxone. Different drugs have different toxic effects, antidotes, and supportive measures, making this information critical to providing appropriate and potentially life-saving care.

Choice B rationale: The time since drug ingestion is important because many interventions, such as gastric lavage or activated charcoal, are time-sensitive. However, without knowing the specific drug, it is difficult to determine whether these interventions are necessary or effective

Choice C rationale: Knowing the reason for the suicide attempt is important for overall assessment and treatment planning but may not provide immediate information for the current situation.

Choice D rationale: Past history of depression is relevant to the client's overall mental health, but in the context of a suspected drug overdose, the time since ingestion takes precedence.

A. Walt for the client to respond. B. Ask if the client heard the question. C. Ask a different question. D. Return at a later time to talk.

Correct Answer is A

Explanation

Choice A rationale: Waiting for the client to respond allows for a patient-centered approach, respecting the client's pace and giving them the opportunity to express themselves when ready.

Choice B rationale: Assuming the client's ability to hear the question may be accurate, but the client's nonverbal cues suggest a need for patience and a non-coercive approach.

Choice C rationale: Changing the question may not address the client's current feelings and might disrupt the therapeutic process.

Choice D rationale: Returning at a later time might be appropriate if the client continues to be unresponsive, but it is not the initial action in this situation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

The nurse interacts with a client who is very depressed and slow to respond to questions. The nurse asks the client to describe current feelings, but the client looks down at the table. Which action is best for the nurse to implement?

Correct Answer is A

Explanation

A young adult client is admitted to a psychiatric facility with a diagnosis of bulimia nervosa. Which nursing intervention has the highest priority?

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?

A client with chronic alcohol dependence is diagnosed with Wernicke-Korsakoff syndrome. The client is experiencing memory loss and confusion. Which medication should the nurse administer to help alleviate the client's symptoms?

After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy. Which action should the nurse implement?

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?

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?