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 D
Explanation
Choice A rationale:
An angiocatheter is not appropriate for accessing an implanted venous access port. Angiocatheters are large-bore catheters designed for rapid fluid administration and are typically used for peripheral venous access. They are not suitable for accessing the small, specialized ports used for central venous access.
Choice B rationale:
A 25-gauge needle is too small for accessing an implanted venous access port. While smaller gauge needles are suitable for delicate procedures and patients with fragile veins, they might not provide adequate flow for certain therapies or blood draws. Accessing a port with a needle that is too small can lead to increased pressure, potentially damaging the port or causing discomfort to the patient.
Choice C rationale:
A butterfly needle is also not the best choice for accessing an implanted venous access port. Butterfly needles, also known as winged infusion sets, are commonly used for short-term peripheral venous access. They are not designed for accessing implanted ports, which require a noncoring needle for precise and safe access without damaging the port membrane.
Choice D rationale:
(Correct Choice) A noncoring needle, also known as a Huber needle, is the correct choice for accessing an implanted venous access port. Noncoring needles have a specially designed tip that creates a smaller puncture hole, reducing damage to the port membrane and minimizing patient discomfort. They are specifically designed for accessing ports and are the standard choice for this procedure.
Correct Answer is B
Explanation
Choice A rationale:
Sitting in high-Fowler's position during the feeding is actually a preventive measure against aspiration. High-Fowler's position, which involves sitting the patient upright at a 90-degree angle, reduces the risk of aspiration by promoting proper digestion and preventing the regurgitation of gastric contents into the lungs.
Choice B rationale:
A history of gastroesophageal reflux disease (GERD) puts the client at risk for aspiration. GERD is a chronic condition in which stomach acid frequently flows back into the esophagus, potentially reaching the throat and lungs, increasing the risk of aspiration during enteral feedings. Aspiration pneumonia, a serious complication, can develop if stomach contents enter the lungs.
Choice C rationale:
A residual of 65 mL 1 hr postprandial indicates that a significant amount of the feeding solution has not been absorbed, raising concerns about delayed gastric emptying. While this situation might require monitoring and adjustments to the feeding regimen, it does not directly increase the risk of aspiration. Aspiration risk is more related to the reflux of stomach contents into the airways.
Choice D rationale:
Receiving a high-osmolarity formula alone does not directly increase the risk of aspiration. High-osmolarity formulas might require careful administration and monitoring to prevent complications, but aspiration risk is more closely associated with the client's underlying conditions, such as GERD.
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