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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The anterior fontanel is open in an 8-month-old infant. The anterior fontanel, located at the top of the baby's head where the skull bones have not yet fused, typically closes between 12 to 18 months of age. It is a normal finding in an 8-month-old infant.
Choice B rationale:
The posterior fontanel closes earlier than the anterior fontanel, usually within the first few months of life. It is a smaller diamond-shaped area located at the back of the baby's head. It is not expected to be open in an 8-month-old infant.
Choice C rationale:
Molding refers to the shaping of the fetal head during passage through the birth canal. It can cause temporary changes in the shape of the baby's skull. By 8 months of age, molding is not an expected finding as the skull bones have had time to return to their normal shape.
Choice D rationale:
Both fontanels being the same size is not a typical finding. The anterior fontanel is larger than the posterior fontanel, and their sizes are proportional. Any significant deviation from this proportion could indicate abnormal skull development and should be further assessed.
Correct Answer is B
Explanation
The correct answer is: b. A room containing personal belongings.
Choice A rationale: A room without a window may lead to disorientation and a lack of natural light, which can disrupt the client's circadian rhythm, contributing to sleep disturbances and mood alterations. Adequate exposure to natural light helps regulate the body's internal clock and promotes a sense of well-being. Furthermore, natural light exposure has been linked to improved cognitive function and mood stability in individuals with cognitive impairments. Therefore, choosing a room with a window is essential for optimizing the client's therapeutic environment.
Choice B rationale: A room containing personal belongings is crucial for creating a therapeutic environment for a cognitively impaired client. Familiar items provide a sense of security and continuity, reducing anxiety and agitation. These belongings serve as anchors to the client's past experiences and identity, facilitating reminiscence therapy and promoting emotional connection. By surrounding the client with familiar objects, the nurse fosters a sense of autonomy and self-expression, empowering the client to engage in meaningful activities and maintain a sense of personal agency.
Choice C rationale: While proximity to the nursing station may facilitate monitoring and prompt intervention in case of emergencies, a room adjacent to the nursing station can also expose the client to constant noise and disruptions. Excessive auditory stimuli can overwhelm a cognitively impaired individual, leading to sensory overload and exacerbating confusion and disorientation. Moreover, the lack of privacy in such a location may compromise the client's dignity and autonomy, hindering their ability to engage in personal activities and interactions. Therefore, placing the client in a quieter, more secluded environment away from the nursing station is preferable for promoting a therapeutic atmosphere conducive to rest and relaxation.
Choice D rationale: Dim lighting poses significant risks for cognitively impaired clients, as it impairs visual perception and increases the likelihood of accidents and falls. Inadequate lighting compromises safety by obscuring obstacles and hazards in the environment, heightening the risk of injuries and fractures. Additionally, dimly lit spaces can exacerbate feelings of fear and anxiety, particularly in individuals with cognitive impairments who may already experience sensory processing difficulties. Bright lighting, on the other hand, enhances visibility and spatial orientation, promoting independence and confidence in daily activities. Therefore, ensuring sufficient illumination in the client's room is essential for mitigating safety hazards and optimizing their overall well-being.
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