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. Speaking in rhyming sentences can be a manifestation of mania but may not necessarily require immediate reporting unless it escalates to disruptive or harmful behavior.
B. Making inappropriate sexual comments can indicate impulsivity and lack of social boundaries. It does not however precede managing the risk of hypoglycemia.
C. Poor hygiene, such as not bathing, is common in mania due to increased energy and decreased need for sleep, but it may not require immediate reporting unless it poses a significant risk to the client's health.
D. Decreased appetite and irregular eating patterns are common during mania due to increased activity levels. Eating twice in teh past is not sufficient to meet energy requirements and the client might be at risk of hypoglycemia.

A. Recommend that the client try to sleep during the day when it is quieter. B. Keep conversations and activities to a minimum during the nighttime. C. Turn on the client's television at night to cover up environmental noises. D. Tell the client that they will eventually get used to people talking at night.

Correct Answer is B

Explanation

A. Encouraging the client to sleep during the day disrupts the natural sleep-wake cycle and may not address the underlying issue of noise disturbances at night.

B. Minimizing conversations and activities during the nighttime promotes a quieter environment conducive to sleep, addressing the client's concern directly.
C. Using a television to cover up noise may not address the root cause of the client's sleep disturbance and could interfere with sleep hygiene.
D. Dismissing the client's concern and suggesting they will eventually get used to the noise does not address the immediate issue or offer practical solutions.

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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

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Explanation

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