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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

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

Answer and Explanation

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

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:

Reaction formation is a defense mechanism where a person behaves in a way opposite to their true feelings.

Choice B rationale:

Somatization is the process of experiencing mental or emotional distress as physical symptoms.

Choice C rationale:

Intellectualization is a defense mechanism where a person uses reasoning to block out emotional stress.

Choice D rationale:

Sublimation is a defense mechanism where a person transforms unacceptable impulses into socially acceptable behaviors.

A. . Make a personal introduction to the client at each interaction. B. Give the client a list of foods to choose from for dinner. C. Repeat orientation questions until the client gives a correct response. D. Provide the client with a dark environment for sleeping.

Correct Answer is A

Explanation

Choice A rationale:

Making a personal introduction to the client at each interaction is a recommended approach for clients with dementia. It helps to orient the client and establish a connection, which can reduce confusion and anxiety.

Choice B rationale:

Giving a client with dementia a list of foods to choose from for dinner may be overwhelming due to impaired decision-making abilities.

Choice C rationale:

Choice D rationale:

Providing a dark environment for sleeping can be disorienting for a client with dementia. A low level of light can help the client maintain orientation to their surroundings.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?.

Correct Answer is B

Explanation

A nurse is assisting with the care of a client who has dementia. Which of the following actions should the nurse take?.

Correct Answer is A

Explanation

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 an older adult client who was admitted with heart failure. The nurse should report which of the following findings to the provider as an indication of delirium? .

A nurse is beginning a therapeutic relationship with a client who has paranoid personality disorder. Which of the following strategies should the nurse plan to use?.

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 is collecting data from a client who has bulimia nervosa. Which of the following findings should the nurse expect?.

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 collecting data from an adult client in an outpatient mental health clinic. The nurse should identify which of the following events as a potential cause of a maturational crisis?.