A nurse is assisting in the admission of a client to an inpatient mental health facility.
The nurse is assisting in the care of the client. Which of the following findings should the nurse report to the charge nurse immediately? Select all that apply.
Medical history
Heart rate
Respiratory rate
Pupils
Oxygen saturation
Orientation
Correct Answer : B,D,F
A. Medical history: While limited medical history may affect care planning, the lack of other medical conditions does not pose an immediate safety concern and does not require urgent reporting.
B. Heart rate: A heart rate of 121/min indicates tachycardia, which, in the context of recent substance injection and agitation, may signal acute toxicity or cardiovascular stress. This finding requires immediate attention and reporting to the charge nurse.
C. Respiratory rate: A respiratory rate of 20/min is within normal limits for an adult and does not indicate immediate compromise. While monitoring is necessary, it does not require urgent reporting.
D. Pupils: Dilated pupils can indicate recent stimulant use or other substance effects, suggesting acute intoxication. This finding may correlate with life-threatening complications and should be reported immediately for safety and intervention planning.
E. Oxygen saturation: Oxygen saturation of 98% on room air is within normal limits and does not indicate hypoxia, so it is not an urgent concern in this context.
F. Orientation: The client is oriented only to person, indicating confusion or impaired cognitive function, possibly due to intoxication or withdrawal. This acute change in mental status is a safety concern and should be reported immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Administer disulfiram: Disulfiram is used for long-term management to discourage alcohol use by causing unpleasant reactions if alcohol is consumed. It is not appropriate during acute alcohol withdrawal, as it does not treat withdrawal symptoms and could be harmful if the client relapses.
B. Complete a CAGE questionnaire every 4 hr: The CAGE questionnaire is a screening tool for identifying alcohol use disorder but is not used for ongoing monitoring of acute withdrawal. Repeating it every 4 hours does not address the immediate clinical needs or risks during withdrawal.
C. Implement seizure precautions: The client exhibits classic signs of alcohol withdrawal, including tremors, diaphoresis, elevated BP, tachycardia, nausea, and anxiety. Severe withdrawal can progress to seizures and delirium tremens. Implementing seizure precautions is essential to prevent injury and ensure safety during acute withdrawal management.
D. Assist with a client referral to Al-Anon: Al-Anon provides support for family members of individuals with alcohol use disorder. While valuable for long-term support, it does not address the client’s acute withdrawal risks and is not the priority intervention during the initial phase of treatment.
Correct Answer is A
Explanation
A. "For now, we should schedule enough time for my partner to complete rituals.": Allowing time for ritualistic behaviors during the initial phase of treatment helps reduce anxiety and prevents conflict. Gradual exposure and response prevention can then be implemented therapeutically, supporting adherence to the treatment plan and a structured environment.
B. "I should ignore the stressors that cause my partner to perform the ritualistic behaviors.": Ignoring triggers does not help manage obsessive-compulsive behaviors and may allow anxiety to escalate. Effective treatment involves recognizing triggers and gradually helping the client manage or tolerate them through therapy.
C. "To prevent stress, we should avoid trying to make a schedule for daily activities.": Structured routines are important for clients with OCD to reduce unpredictability and associated anxiety. Avoiding a schedule may worsen symptoms rather than supporting treatment goals.
D. "I should expect my partner to begin exhibiting paranoid behaviors.": Paranoia is not a typical feature of obsessive-compulsive disorder. Expecting paranoid behaviors reflects a misunderstanding of the disorder and does not align with evidence-based treatment planning.
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