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. Instructing the client about the importance of regular medical appointments is important but not the priority because it is a secondary prevention strategy that aims to detect and treat any complications or changes in the client's condition early. The client should have regular follow-up visits with an endocrinologist, a diabetes educator, an ophthalmologist, a podiatrist, a dentist, and other health care providers as needed.
B. Encouraging the client to participate in daily exercise is important but not the priority because it is a tertiary prevention strategy that aims to reduce disability and improve quality of life for clients with chronic conditions. Exercise can help lower blood glucose levels, improve insulin sensitivity, reduce cardiovascular risk factors, enhance mood, and promote weight management for clients with type 1 diabetes mellitus. The client should consult with their health care provider before starting an exercise program and follow safety guidelines such as checking blood glucose levels before and after exercise, wearing appropriate footwear and clothing, carrying a source of fast-acting carbohydrate, and staying hydrated.
C. Explaining proper foot care techniques to the client is important but not the priority because it is a tertiary prevention strategy that aims to prevent or minimize complications such as foot ulcers, infections, and amputations for clients with type 1 diabetes mellitus. Foot care includes inspecting feet daily for any injuries or abnormalities, washing feet with mild soap and warm water, drying feet thoroughly especially between toes, applying moisturizer to prevent dryness and cracking, trimming toenails straight across and filing edges smooth, wearing clean cotton socks and well-fitting shoes, avoiding walking barefoot or exposing feet to extreme temperatures or pressure, and seeking medical attention for any foot problems.
D. Ensuring that the client understands the medication regimen is the nurse's priority because type 1 diabetes mellitus requires lifelong insulin therapy to maintain blood glucose levels within normal range and prevent complications such as ketoacidosis, hypoglycemia, and organ damage. The client needs to know how to administer insulin injections, monitor blood glucose levels, adjust insulin doses according to carbohydrate intake and physical activity, recognize and treat signs and symptoms of hypo- and hyperglycemia, and store insulin properly.
Correct Answer is ["A","B","C","D","E","F"]
Explanation
A. This is a correct action. Firmly massaging the uterine fundus can help contract the uterus and reduce bleeding by expelling clots and compressing blood vessels.
B. This is a correct action. Providing emotional support can help calm the client and reduce anxiety, which can worsen bleeding by increasing heart rate and blood pressure.
C. This is a correct action. Administering oxygen can help improve tissue perfusion and oxygenation, which can prevent hypoxia and shock due to blood loss.
D. This is a correct action. Weighing the perineal pads can help estimate the amount of blood loss and monitor the effectiveness of interventions to control bleeding.
E. This is a correct action. Inserting an indwelling urinary catheter can help empty the bladder and prevent it from displacing or compressing the uterus, which can interfere with uterine contraction and increase bleeding.
F. This is a correct action. Administering methylergonovine can help stimulate uterine contraction and reduce bleeding by constricting blood vessels in the uterus.
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