Try Naxlex NCLEX-RN (Free-Trial)

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

Answer and Explanation

Correct Answer : B,C,E

The correct answer is B, C, and E.

A. Weight is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition.
B. Neuro status is a correct choice because it reflects the client's level of consciousness, orientation, memory, and cognitive function. Any alteration in neuro status could indicate a serious problem such as infection, stroke, or medication toxicity.
C. Auditory hallucinations are a correct choice because they are a symptom of psychosis and could indicate a relapse or worsening of the client's mental illness. Auditory hallucinations could also impair the client's ability to cope, communicate, and function effectively.
D. Speech is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition. Speech could be affected by various factors such as mood, anxiety, or medication side effects.
E. Restlessness is a correct choice because it is a sign of agitation, anxiety, or discomfort. Restlessness could also indicate an underlying physical or psychological problem such as pain, infection, or psychosis.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale:

Instructing the client to maintain a full bladder is not relevant to an amniocentesis procedure. A full bladder may be necessary for certain other procedures, such as a pelvic ultrasound, but not for amniocentesis.

Choice B rationale:

Administering a tocolytic 30 minutes before the procedure is not a standard practice for amniocentesis. Tocolytics are medications used to suppress uterine contractions and are not routinely administered before this procedure.

Choice C rationale:

Monitoring the fetal heart rate throughout the procedure is essential during an amniocentesis. This helps assess the well-being of the fetus and ensures that the procedure is not causing fetal distress. Any changes in fetal heart rate can indicate potential complications and may require immediate intervention.

Choice D rationale:

Placing the client in Trendelenburg position during the procedure is not recommended for amniocentesis. Trendelenburg position, where the body is supine with the legs elevated higher than the head, is not routinely used during this procedure and may cause discomfort to the client without providing significant clinical benefits.

A. Discuss the suspicion of physical abuse with the provider. B. Confront the parents with the suspicion of physical abuse. C. Ask the hospital security to detain and question the parents. D. Contact Child Protective Services.

Correct Answer is D

Explanation

- A. Discussing the suspicion of physical abuse with the provider is the appropriate action for the nurse to take. However, this should be done after the matter is reported to child protection services.

- B. Confronting the parents with the suspicion of physical abuse is not an appropriate action for the nurse to take, as it can escalate the situation and endanger the child or the nurse.

- C. Asking the hospital security to detain and question the parents is not an appropriate action for the nurse to take, as it violates the parents' rights and may interfere with the legal process.

- D.Contacting Child Protective Services is appropriate action for the nurse to take at this point as it is the nurse's legal responsibility to do so.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse in an outpatient mental health clinic is caring for a client. Select the 3 findings that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client prior to an amniocentesis.Which of the following actions should the nurse include in the plan of care?

Correct Answer is C

Explanation

A nurse in an emergency department is assessing a school-age child who was brought in by their parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take?

A nurse is teaching about adverse effects with a client who is starting to take captopril. Which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider?

A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60 mm Hg, and HCO3 of 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances?

A community health nurse is developing a plan of care for an older adult client who has type 2 diabetes mellitus and lives independently in a rural area.Which of the following interventions should the nurse include?

An RN is observing a licensed practical nurse (LPN) and an assistive personnel (AP) move a client up in bed. For which of the following situations should the nurse intervene?

A nurse is caring for a group of clients. Which of the following clients should the nurse attend to first?

A nurse is preparing to replace a client's transdermal fentanyl patch after 72 hr of use. After the nurse opens the packet containing the new pouch, the client declines to accept it. Which of the following actions should the nurse take?

A nurse is assigning task roles for a group of clients in a community mental health clinic. Which of the following tasks should the nurse assign to the member of the group functioning as the orienteer?