A nurse is assisting in the care of a client in the emergency department (ED). Nurses' Notes 0205: Client brought to the ED by police after being found wandering on the street.

Client able to provide identity to police but not able to identify place or time.

Family notified.

Client confused and agitated.

Appearance is disheveled.

Mucous membranes dry.

Lungs clear and equal, heart rhythm regular.

During data collection, the client states, "Can you ask that person to leave my room?" Client is pointing to an empty chair.

Vital Signs 0200: Temperature 38.6°C (101.5°F), Heart rate 104/min, Respiratory rate 18/min, Blood pressure 158/96 mm Hg, Oxygen saturation 98% on room air.

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Client confused and agitated.

Appearance is disheveled.

Mucous membranes dry

During data collection, the client states, "Can you ask that person to leave my room?" Client is pointing to an empty chair.

Temperature 38.6°C (101.5°F)

Blood pressure 158/96 mm Hg

Heart rate 104/min

Respiratory rate 18/min

Oxygen saturation 98% on room air.

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F"]

The findings that require immediate follow-up are:

Client confused and agitated: This could indicate a neurological issue or other serious condition that needs immediate attention.
Appearance is disheveled: This could suggest neglect or other issues that need to be addressed.
Mucous membranes dry: This could indicate dehydration which can be serious if not addressed promptly.
Client states “Can you ask that person to leave my room?” Client is pointing to an empty chair: This could indicate hallucinations or other mental health concerns that need immediate attention.
Temperature 38.6°C (101.5°F): This is a fever and could indicate an infection or other medical condition that needs immediate attention.
Blood pressure 158/96 mm Hg: This is high and could indicate hypertension or other cardiovascular issues that need immediate attention.

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Correct Answer is B

Explanation

Choice A rationale:

This statement is incorrect. Opioid withdrawal typically results in tachycardia, not bradycardia.

Choice B rationale:

This statement is correct. Diarrhea is a common symptom of opioid withdrawal.

Choice C rationale:

This statement is incorrect. Opioid withdrawal often results in restlessness and agitation, not hypokinesis.

Choice D rationale:

This statement is incorrect. Opioid withdrawal typically results in dilated pupils, not meiosis.

A. A client who has bipolar disorder and is continuously pacing at the end of the hall. B. A client who is standing in her room, yelling obscenities and throwing her clothes. C. A client in the dayroom who is screaming at other clients about what is on the television. D. A client who is repeatedly approaching the nurses' station to request medication for his anxiety.

Correct Answer is B

Explanation

Choice A rationale:

While pacing can indicate anxiety, this client is not currently a threat to themselves or others.

Choice B rationale:

This client is exhibiting aggressive behavior and could potentially harm themselves or damage property.

Choice C rationale:

Although this client’s behavior is disruptive, it is not immediately dangerous.

Choice D rationale:

This client’s repeated requests indicate anxiety, but they are not in immediate danger.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect?.

Correct Answer is B

Explanation

A nurse is caring for multiple clients on a mental health unit. Which of the following clients should the nurse attend to first?.

Correct Answer is B

Explanation

A nurse is collecting data for a health history from a client who has antisocial personality disorder. Which of the following clinical findings is associated with this disorder?.

A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states, "That looks like a snake, and I won't let it take all of my blood.”. Which of the following responses should the nurse make?.

A nurse is assisting with teaching a group of older adult clients about behavioral expectations. Which of the following actions should the nurse take to help eliminate barriers to learning?.

A nurse is caring for a client who has an anxiety disorder. The client transforms their anxiety into physical manifestations. The nurse should recognize that the client is ing which of the following manifestations?.

A nurse is contributing to the plan of care for a client who has a new prescription for lithium. Which of the following interventions should the nurse recommend?.

A nurse is caring for a group of clients in a pediatric clinic. Which of the following clients is at the highest risk for physical abuse? .

The nurse has reviewed the nurses' notes, provider's note, and vital signs at 0400. Exhibits For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.

A nurse is assisting with reminiscence therapy for a group of older adult clients. Which of the following strategies should the nurse implement? .