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 C

Explanation

Choice A rationale:
Using an incentive spirometer is not directly related to the post-TUNA discharge instructions for a client with BPH. Incentive spirometry is typically used to improve lung function and prevent respiratory complications.

Choice B rationale:
Monitoring the urinary stream for a decrease in output may be important, but it is a general instruction that may not be specific to the TUNA procedure. The primary focus after TUNA is often on monitoring for complications related to the procedure.

Choice C rationale:
Reporting when hematuria (blood in the urine) becomes pink-tinged is important. While some degree of hematuria is expected after TUNA, a change in color to pink or any other concerning changes should be reported to the healthcare provider as it could indicate complications.

Choice D rationale:
There is typically no need to restrict physical activities after a TUNA procedure. In fact, healthcare providers often encourage patients to resume normal activities gradually unless otherwise instructed due to specific complications.

A. The nurse will call the client weekly to monitor the client's blood pressure and symptoms. B. The nurse will encourage the client to walk thirty minutes every day. C. The client will take up to 4 nitroglycerine tablets sublingually for chest pain. D. The client will record episodes of angina and self-management for one week.

Correct Answer is D

Explanation

Choice A rationale:
Weekly monitoring of blood pressure and symptoms is important but does not address the specific issue of chest pain on exertion.

Choice B rationale:
Encouraging daily walking is generally a good recommendation for overall health but does not address the immediate concern of chest pain.

Choice C rationale:
Taking up to 4 nitroglycerine tablets for chest pain may provide temporary relief, but this should be done under the guidance of a healthcare provider and is not a long-term outcome.

Choice D rationale:
Recording episodes of angina and self-management for one week is a specific and appropriate outcome to monitor the client's chest pain and response to interventions.

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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

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?

Correct Answer is C

Explanation

The nurse is developing a plan of care for an older client with hypertension who reports chest pain on exertion. Which outcome should the nurse include in the plan of care for this client?

Correct Answer is D

Explanation

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 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.

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?

A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

When the nurse addresses questions to an adult female client who is depressed, the client's responses are delayed. Which intervention should the nurse include in this client's plan of care?