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
Choice A reason
Ensuring that the client's family supports the provider's decision for surgery is not an appropriate action. While family support is essential in the decision-making process, the primary responsibility lies with the client's health care surrogate or designated decision-maker. The family's support is not a substitute for obtaining informed consent from the designated decision-maker.
Choice B reason
Sending the unsigned informed consent form to the facility's risk manager is not appropriate action. The nurse should not send an unsigned informed consent form to the facility's risk manager. Unsigned consent forms do not have any legal significance or validity. The nurse should work with the health care surrogate to ensure that the consent form is appropriately completed and signed.
Choice C reason
Determining if the procedure is medically necessary for the client is not appropriate action. While the medical necessity of the procedure is important, the decision about the procedure's necessity should be made by the medical team and discussed with the health care surrogate. The nurse's role is to facilitate communication and ensure that the surrogate is informed and involved in the decision-making process.
Choice D reason
When a client is in a coma and unable to provide informed consent, the health care surrogate or designated decision-maker becomes responsible for making medical decisions on behalf of the client. It is essential for the nurse to ensure that the health care surrogate is aware of the situation, understands the risks and benefits of the surgical procedure, and has provided informed consent on behalf of the client.
Correct Answer is A
Explanation
A. Radial vein of the inner arm. This is correct because this site is easily accessible, has good blood flow, and has less risk of complications such as infection, thrombosis, or infiltration.
B. Great saphenous vein of the leg. This is incorrect because this site is not recommended for older adults due to poor circulation, increased risk of thrombophlebitis, and difficulty in monitoring.
C. Dorsal plexus vein of the foot. This is incorrect because this site is prone to edema, infection, and injury, and can interfere with mobility and comfort.
D. Basilic vein of the hand. This is incorrect because this site is more painful, has smaller veins, and can cause nerve damage or occlusion if not inserted carefully.
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