A nurse in a mental health facility is caring for a group of clients. After assessing the clients, which of the following clients requires an update to their plan of care to ensure client safety?

A client who has anorexia nervosa and expresses a fear of gaining weight

A client who has bipolar disorder and is exhibiting poor impulse control

A client who has schizophrenia and is exhibiting clang associations in their speech

A client who has Alzheimer's disease and is having difficulty remember names of family members

Answer and Explanation

The Correct Answer is B

A.   While a client with anorexia nervosa may require close monitoring and support, expressing a fear of gaining weight does not necessarily indicate an immediate safety concern that requires an update to the plan of care.

B.   Bipolar disorder can involve manic episodes characterized by impulsivity and risk-taking behaviors. Exhibiting poor impulse control indicates a potential safety concern that requires an update to the plan of care to ensure the client's safety and the safety of others.
C.   Clang associations in speech are a symptom of disorganized thinking commonly seen in schizophrenia. While it may indicate a need for intervention, it does not necessarily require an immediate update to the plan of care for safety reasons.
D.   Difficulty remembering names of family members is a symptom of Alzheimer's disease and may require ongoing support and management but does not present an immediate safety concern that requires an update to the plan of care.

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Correct Answer is D

Explanation

A. Administering medications, such as atropine, requires nursing judgment and assessment of the client's condition, which should not be delegated to assistive personnel.
B. Witnessing the client's signature on the consent form ensures that the client provides informed consent for the procedure and requires nursing judgment.
C. Assessing the client's condition after the procedure involves monitoring vital signs, level of consciousness, and potential adverse reactions, which require nursing assessment and judgment.
D. Assisting the client to ambulate after the procedure is a task that can be safely delegated to assistive personnel, as long as the client's condition is stable and there are no contraindications to ambulation.

A. "Have you been thinking about harming yourself?" B. "Why do you feel like things will never work out?" C. “You should try to focus on yourself for a change." D. “Maybe an antidepressant will make you feel better."

Correct Answer is A

Explanation

A. This response directly addresses the potential for self-harm, which is a critical concern when a client expresses hopelessness. It is an open-ended question that invites the client to discuss their feelings and provides the nurse with information to assess the client's safety.
B. Asking the client a why question may not be alright and this may make them to be guarded.
C. This response may come off as dismissive and lacks empathy towards the client's feelings.
D. Suggesting medication without further assessment is premature and may not address the root cause of the client's statement.

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A nurse in a mental health facility is caring for a group of clients. After assessing the clients, which of the following clients requires an update to their plan of care to ensure client safety?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is undergoing electroconvulsive therapy. Which of the following tasks should the nurse delegate to an assistive personnel?

Correct Answer is D

Explanation

A nurse is caring for a client who states, "Things will never work out." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a client in an inpatient mental health facility. The client tells the nurse that the government is reading her mail. Which of the following responses should the nurse make?

A nurse is assessing a client's communication patterns. The client states, "My partner is always criticizing me." This statement is an example of which of the following types of dysfunctional communication?

A nurse is reviewing new prescriptions for a client who is experiencing acute manifestations of alcohol withdrawal. Which of the following medications should the nurse expect the provider to prescribe for this client?

A nurse is talking with a newly licensed nurse about client rights while admitted to a mental health facility. Which of the following information should the nurse include? (Select all that apply.)

A nurse is caring for a client who has antisocial personality disorder and reports planning to hurt their partner upon discharge. Which of the following actions should the nurse take?

A nurse is assessing a client who has bipolar disorder. Which of the following findings should the nurse identify as an indication that the client is experiencing acute mania?

A nurse in an acute care facility is planning care for a client who has a history of alcohol use disorder and is admitted while intoxicated. Which of the following interventions should the nurse plan for the client?

A nurse in an emergency department is assessing a client who reports recently using cocaine.Which of the following clinical manifestations should the nurse expect?