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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Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale:

Checking blood pressure once a week is a good practice, especially for clients on medications that can affect blood pressure.

Choice B rationale:

Chewing sugar-free gum several times daily is not harmful and can help with dry mouth, a common side effect of haloperidol.

Choice C rationale:

Avoiding alcohol while taking haloperidol is recommended as alcohol can increase the side effects of the medication.

Choice D rationale:

Spending several hours a day outside gardening when it’s sunny can lead to a condition called photosensitivity, a side effect of haloperidol. The client should be advised to wear protective clothing and sunscreen when outside.

A. Alcohol use disorder B. Currently married. C. Access to guns in the home. D. Sibling history of suicide. E. Terminal liver cancer.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A rationale:

Alcohol use disorder is a risk factor for suicide. Alcohol can increase impulsivity and decrease inhibitions, which can lead to suicidal behaviors.

Choice B rationale:

Being currently married is generally considered a protective factor against suicide, not a risk factor.

Choice C rationale:

Access to lethal means, such as guns in the home, is a significant risk factor for suicide.

Choice D rationale:

A family history of suicide, including a sibling history of suicide, is a risk factor for suicide.

Choice E rationale:

Terminal illnesses, such as liver cancer, can increase feelings of hopelessness and despair, which are risk factors for suicide.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who started taking haloperidol decanoate 125 mg IM 1 month ago. Which of the following statements by the client should the nurse address?.

Correct Answer is D

Explanation

A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide. Which of the following findings should the nurse identify as a risk factor for suicide? (Select all that apply.) .

Correct Answer is ["A","C","D","E"]

Explanation

A nurse is participating in a community program about eating disorders. Which of the following information about bulimia nervosa should the nurse include in the presentation?.

A nurse in a substance use disorder clinic is explaining the alcohol recovery process to a client's family. Which of the following should the nurse identify as the first step toward successful recovery from alcohol use disorder?.

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

A nurse is reinforcing teaching with a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?.

A nurse is caring for a client who has an opioid use disorder. The nurse should anticipate that the provider will prescribe which of the following medications for treatment?.

A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior. Which of the following actions should the nurse take?.

A nurse is contributing to the plan of care for a client who has acute delirium. Which of the following interventions should the nurse include in the plan of care? .