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 B
Explanation
A. This choice is incorrect because forgetting to buy a gift is not an example of dissociation, but rather a sign of poor memory or lack of attention.
B. This choice is correct because describing the abuse as if it happened to someone else is an example of dissociation, which is a defense mechanism that involves separating oneself from painful or traumatic experiences.
C. This choice is incorrect because being verbally assertive is not an example of dissociation, but rather a personality trait or a coping skill.
D. This choice is incorrect because blaming the boss for not getting a promotion is not an example of dissociation, but rather a sign of external locus of control or rationalization.
Correct Answer is A
Explanation
A. Correct. Designating a health care surrogate is one of the components of an advance directive, which allows the client to appoint someone who can make medical decisions on their behalf if they are unable to do so themselves.
B. Incorrect. Age is not a factor that determines the need for an advance directive, as anyone can become incapacitated at any time due to illness or injury.
C. Incorrect. A lawyer's help is not necessary to draw up an advance directive, as there are standardized forms available that can be filled out by the client and witnessed by two adults.
D. Incorrect. The family cannot alter or override the advance directives of the client unless they have been designated as their health care surrogate or have obtained a court order to do so.
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