A nurse is assisting in the care of a client on an acute care mental health unit.
Select words from the choices to fill in each blank in the following sentence.
The nurse should immediately follow up on the client's
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"D"}
Rationale for correct choices
• Mood: A sudden improvement in mood after days of depression can indicate the client has developed the energy or resolve to act on suicidal thoughts. This shift requires immediate follow‑up to reassess suicide risk and ensure safety precautions remain appropriate.
• Energy level: An increase in energy during early recovery from severe depression may enable a client to carry out self‑harm plans formed earlier. Asking to jog and planning future tasks can signal rising activation, which requires prompt reassessment of suicide intent and safety needs.
Rationale for incorrect choices
• Substance use history: While relevant to overall care, the client’s substance use history is unchanged in this scenario and does not account for the acute risk shift. It does not require immediate follow‑up in response to the new presentation.
• Cognitive orientation: Orientation remained intact on both days and does not indicate a change in risk level. There is no evidence of worsening confusion or impaired cognition that would necessitate urgent reassessment.
• Family history: Maternal anxiety history is background information and does not influence the immediate safety concern. It does not require urgent follow‑up compared to the significant changes in mood and energy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.8"]
Explanation
Calculation:
- Identify the ordered dose and available concentration
Ordered Dose: 4 mg
Available Concentration: 5 mg/mL
- Calculate the volume to administer
Volume to administer = Ordered Dose ÷ Concentration
Volume to administer = 4 ÷ 5
Volume to administer = 0.8 mL
Correct Answer is A
Explanation
A. Fluctuating level of orientation: A sudden or fluctuating change in orientation is a hallmark sign of delirium, particularly in older adults with acute medical conditions like heart failure. Reporting this to the provider is crucial because delirium often indicates an underlying acute illness or metabolic imbalance that requires immediate attention.
B. Consistent state of depression: Depression typically presents as a stable, persistent low mood rather than an acute fluctuation in cognition. While important to recognize, it does not indicate delirium and is not usually an immediate medical emergency.
C. Demonstrates obsessive behaviors: Obsessive behaviors are more characteristic of chronic psychiatric conditions such as obsessive-compulsive disorder and are not indicative of delirium. These behaviors do not reflect an acute change in cognitive status.
D. Family report of gradual memory loss: Gradual memory loss is more consistent with dementia, which develops slowly over time. Delirium differs in that it has an abrupt onset and fluctuating course, requiring urgent evaluation and management.
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