A nurse in an outpatient mental health clinic is caring for a client.
Exhibit 1
Vital Signs
3 months ago:
Blood pressure 116/68 mm Hg
Heart rate 82/min
Respiratory rate 16/min
Temperature 36.7° C(98.1° F)
SaO2 97% on room air
Today:
Blood pressure 128/76 mm Hg
Heart rate 104/min
Respiratory rate 22/min
Temperature 37.4° C(99.4° F)
SaO2 97% on room air
Exhibit 2
Nurses' Notes
3 months ago:
Client recently admitted with new diagnosis of schizophrenia. Received inpatient treatment for 10 days and was discharged 1 week ago. Client is alert and oriented to person, place, time, and situation. Responds appropriately to questions. Client reports sleeping well and working at a local retail store.
Today:
Client presents for follow-up visit. Pressured speech noted.
Appears to be listening to unseen others. Client is restless.
Frequently getting out of chair. Appears tired and disheveled.
Exhibit 3
Graphic Record
3 months ago:
83.9 kg (185 lb)
Today:
83 kg(183 lb)
A nurse in an outpatient mental health clinic is caring for a client. Select the 3 findings that require immediate follow-up.
Weight
Neuro status
Auditory hallucinations
Speech
Restlessness
Correct Answer : C,D,E
A.The client's weight has remained relatively stable (83.9 kg to 83 kg), which does not indicate an immediate health concern compared to the acute behavioral and mental health symptoms observed.
B. While the client's neurostatus (mental status) is affected by the presence of auditory hallucinations, pressured speech, and restlessness, these symptoms are more critical in terms of immediate management than a general assessment of neurologic status.
C. Auditory hallucinations, such as appearing to listen to unseen others, are concerning symptoms indicating possible exacerbation of schizophrenia or medication non-compliance. Immediate assessment and intervention by mental health professionals are needed.
D. Pressured speechis commonly seen in mania or anxiety.Poverty of speechcan be associated with shyness, depression, schizophrenia, or cognitive impairment. Pressured speech noted along with other symptoms can indicate agitation or worsening of mental health symptoms. It suggests the client may be experiencing an acute phase of their illness, requiring evaluation and possibly adjustment of medications.
E. Restlessness, frequently getting out of the chair, and appearing tired and disheveled indicate agitation and potential agitation or anxiety. This could be a sign of increased agitation, anxiety, or distress, which needs immediate attention to prevent escalation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Flexing the client's neck forward can increase intracranial pressure by impeding venous drainage from the brain and increasing cerebral blood volume. Therefore, this choice is incorrect.
B. Grouping several nursing activities to be completed at one time can increase intracranial pressure by stimulating the client and causing fluctuations in blood pressure and heart rate. Therefore, this choice is incorrect.
C. Limiting suctioning the client's airway to 30 seconds at a time can reduce intracranial pressure by minimizing hypoxia and hypercarbia, which can cause cerebral vasodilation and increased cerebral blood volume. However, this intervention alone is not sufficient to prevent increased intracranial pressure, and suctioning should be done only when necessary and with caution. Therefore, this choice is partially correct but not the best answer.
D. Placing the client in a quiet environment can reduce intracranial pressure by minimizing sensory stimulation and promoting relaxation, which can lower blood pressure and heart rate and decrease cerebral metabolic demand. Therefore, this choice is correct and the best answer.
Correct Answer is C
Explanation
A. Hypotension is not an adverse effect of epinephrine, but rather a sign of anaphylaxis that epinephrine can help to reverse by causing vasoconstriction and increasing blood pressure.
B. Report of tinnitus is not an adverse effect of epinephrine, but rather a symptom of aspirin toxicity, which can occur in some clients who take aspirin for allergic reactions.
C. Report of chest pain is an adverse effect of epinephrine, as it can cause cardiac dysrhythmias, angina, and myocardial ischemia by increasing the heart rate and oxygen demand of the myocardium.
D. Ecchymosis is not an adverse effect of epinephrine, but rather a sign of bleeding disorders or trauma that can cause bruising under the skin.
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