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 C
Explanation
A. Incorrect. The client does not have respiratory alkalosis because respiratory alkalosis is characterized by a low PaCO2 (less than 35 mm Hg) and a high pH (greater than 7.45).
B. Incorrect. The client does not have metabolic alkalosis because metabolic alkalosis is characterized by a high HCO3 (greater than 26 mEq/L) and a high pH (greater than 7.45).
C. Correct. The client has respiratory acidosis because respiratory acidosis is characterized by a high PaCO2 (greater than 45 mm Hg) and a low pH (less than 7.35).
D. Incorrect. The client does not have metabolic acidosis because metabolic acidosis is characterized by a low HCO3 (less than 22 mEq/L) and a low pH (less than 7.35).
Correct Answer is ["A","B","C"]
Explanation
A. Assess peripheral circulation hourly. This is correct because clients with SCD are at risk of vaso-occlusive crisis, which can impair blood flow to the extremities and cause tissue ischemia and necrosis. The nurse should monitor for signs of poor circulation such as pallor, coolness, numbness, or pain.
B. Assess the client's mouth every 8 hr. This is correct because clients with SCD are prone to oral ulcers, infections, and dental problems due to chronic anemia and reduced oxygen delivery to the oral mucosa. The nurse should inspect the mouth for lesions, bleeding, inflammation, or infection and provide oral hygiene as needed.
C. Use humidification with oxygen therapy. Administer IV fluids. This is correct because clients with SCD need adequate hydration and oxygenation to prevent sickling of red blood cells and further complications. Humidification helps moisten the airways and prevent dehydration of the mucous membranes. IV fluids help maintain fluid and electrolyte balance and reduce blood viscosity.
D. Raise the knee position on the client's bed. This is incorrect because this can impede venous return and worsen peripheral circulation. The nurse should keep the client's extremities in a neutral position and avoid tight or restrictive clothing or devices.
E. Use an automated blood pressure cuff on the client's arm. Prepare for platelet transfusion. This is incorrect because this can cause mechanical trauma to the arm and trigger a vaso-occlusive crisis. The nurse should use a manual blood pressure cuff and avoid applying pressure to the arm. Platelet transfusion is not indicated for clients with SCD unless they have thrombocytopenia or bleeding.
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