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?

Compromised family coping.

Ineffective sexual patterns.

Impaired environmental interpretation.

Disturbed sensory perception.

Answer and Explanation

The Correct Answer is D

Choice A rationale:
Compromised family coping may be a concern, but it is not the most immediate priority given the client's symptoms of altered reality.

Choice B rationale:
Ineffective sexual patterns is not the primary concern in this scenario, as the client's delusional beliefs and hallucinations take precedence.

Choice C rationale:
Impaired environmental interpretation may be relevant, but it is not the most immediate priority compared to addressing the client's altered perception of reality.

Choice D rationale:
The client's delusional beliefs and hallucinatory experiences suggest disturbed sensory perception, which is a priority nursing problem that requires immediate attention and intervention. These symptoms may indicate a serious mental health condition, such as psychosis, that necessitates psychiatric evaluation and care.

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Correct Answer is A

Explanation

Choice A rationale:
It is crucial to obtain information about any history of heart disease before starting an antidepressant-like sertraline because certain antidepressants can have effects on the heart's electrical conduction system. Sertraline, in particular, may be associated with QT interval prolongation, and individuals with a history of heart disease may be at higher risk. Assessing this history helps the nurse make informed decisions about the client's treatment and potential risks.

Choice B rationale:
While a familial history of mental illness is important to consider, it is not the most critical information to obtain before starting sertraline. The primary concern with sertraline is its potential impact on the heart's electrical conduction system, making option A (heart disease history) more relevant.

Choice C rationale:
Current weight is essential to monitor during treatment with sertraline as it can impact dosing, but it is not the most critical piece of information to obtain before starting the medication.

Choice D rationale:
Medication history is important but not the most critical information in this context. Assessing any history of heart disease (Option A) takes precedence due to the specific cardiovascular risks associated with sertraline.

A. Request backup from the staff. B. Stand in the doorway. C. Provide for personal space. D. Encourage the client to sit down.

Correct Answer is C

Explanation

Choice A rationale:
Requesting backup from the staff may be necessary if the situation escalates further, but it is not the initial action to take. Providing for personal space and attempting to de-escalate the situation should come first.

Choice B rationale:
Standing in the doorway may not be the most effective approach because it doesn't actively address the client's agitation or attempt to de-escalate the situation.

Choice C rationale:
Providing personal space is an important initial intervention when dealing with an agitated client. This approach helps maintain safety for both the nurse and the client and can reduce the perception of threat or intrusion.

Choice D rationale:
Encouraging the client to sit down may be a helpful de-escalation technique, but it should come after providing for personal space to ensure safety and reduce tension.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?

Correct Answer is A

Explanation

When responding to a call light, the nurse finds a client with aggressive behaviors pacing, and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?

Correct Answer is C

Explanation

The nurse plans to use role-playing as a therapeutic measure. Which individual is most likely to benefit from this type of therapeutic intervention?

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

A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2. Which action(s) should the nurse take in response to these findings? (Select all that apply.)

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

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?

The nurse is assessing a client whose spouse died of a stroke two weeks ago and who reports having numbness and tingling on the right side of the body. The nurse should consider the client's symptoms may likely be due to which condition.