A nurse in an acute mental health care facility is prioritizing care for multiple clients.
Which of the following clients should the nurse see first?

A client who has obsessive-compulsive disorder and is upset about a change in daily routine.

A client who is taking clozapine to treat schizophrenia and reports a sore throat.

A client who has narcissistic personality disorder and is mocking others during group therapy.

A client who has depressive disorder and requires assistance with ADLs.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

A client with obsessive-compulsive disorder being upset about a change in daily routine is concerning but does not present an immediate threat to their physical health or require urgent attention compared to a potential medical emergency like a sore throat.

Choice B rationale:

Clozapine, an atypical antipsychotic, can cause agranulocytosis, a potentially life-threatening condition characterized by a severe reduction in white blood cell count. Sore throat could be an early sign of this serious adverse effect. Therefore, a client taking clozapine reporting a sore throat requires immediate evaluation to rule out agranulocytosis, which can progress rapidly if not addressed promptly.

Choice C rationale:

A client with narcissistic personality disorder mocking others during group therapy is disruptive and inappropriate behavior but does not require immediate attention unless it escalates into a situation that threatens the safety of others or the therapeutic environment.

Choice D rationale:

A client with depressive disorder requiring assistance with activities of daily living (ADLs) needs support and care, but this does not indicate an urgent situation. While assistance with ADLs is important for the client's well-being, it is not a priority over a potential medical emergency like agranulocytosis.

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Correct Answer is B

Explanation

Choice A rationale:

Administering a laxative to a client with acute appendicitis is contraindicated. Laxatives can increase bowel motility, which may aggravate the inflamed appendix and lead to rupture. Rupture of the appendix can result in a life-threatening condition known as peritonitis.

Choice B rationale:

Keeping the client on NPO (nothing by mouth) status is the correct choice. NPO status is essential in the management of acute appendicitis. It helps to rest the bowel, prevents stimulation of the appendix, and decreases the risk of rupture. Oral intake, including food and fluids, is usually restricted until the client undergoes surgery to remove the inflamed appendix (appendectomy).

Choice C rationale:

Placing the client's head of bed flat is not the optimal position for a client with acute appendicitis. Elevating the head of the bed slightly (semi-Fowler's position) can help reduce discomfort and minimize pressure on the abdomen. This position is more comfortable for the client and can aid in pain management.

Choice D rationale:

Applying heat to the client's abdomen is not recommended in acute appendicitis. Heat application can increase blood flow to the area, potentially worsening inflammation and exacerbating pain. Cold packs or ice packs are sometimes used to provide comfort, but their application should be done cautiously to avoid skin damage. However, in many cases, healthcare providers prefer to avoid temperature applications to prevent masking symptoms and signs of worsening appendicitis.

A. A client who has a prescription for compression stockings and did not receive them. B. A client who consumes all the food from their meal tray. C. A client who requests to sit in the bedside chair while watching TV. D. A client who requests assistance to use the bedside commode.

Correct Answer is A

Explanation

Choice A rationale:

The nurse should instruct the assistive personnel (AP) to report the client who has a prescription for compression stockings but did not receive them. This situation involves a missed intervention that is crucial for the client's health and safety. Reporting this to the nurse allows timely intervention and ensures that the client receives the necessary care.

Choice B rationale:

Consuming all the food from the meal tray is not a cause for concern and does not require immediate reporting to the nurse. It is a normal behavior and does not indicate any potential issues with the client's health or safety.

Choice C rationale:

The client's request to sit in the bedside chair while watching TV is a common and appropriate request. It does not pose any risk to the client's health or safety and does not require immediate reporting to the nurse.

Choice D rationale:

A client requesting assistance to use the bedside commode indicates a need for assistance with a basic activity of daily living. The AP should assist the client with this request as appropriate and does not need to report it to the nurse unless complications or concerns arise during the process.

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A nurse in an acute mental health care facility is prioritizing care for multiple clients.Which of the following clients should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has acute appendicitis.Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

A nurse and an assistive personnel (AP) are assigned a group of clients on the unit.Which of the following clients should the nurse instruct the AP to report to the nurse?

Correct Answer is A

Explanation

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A nurse in an acute mental health care facility is prioritizing care for multiple clients.
Which of the following clients should the nurse see first?