A nurse is caring for a client who has a serious mental illness. The client's temperature is 37° C (98.6° F), respiratory rate is 18/min, heart rate is 102/min, and blood pressure is 202/98 mm Hg. The client is wearing a heavy coat and scarf. The temperature is 37.8° C (100° F) outside. The client reaches for the nurse and says. "Kiss me baby! You know you want to!" Which of the following findings should the nurse address first?
Blood pressure
Heart rate
Comment to the nurse
Clothing choice of heavy coat
The Correct Answer is C
C. The nurse should address the client's inappropriate and boundary-crossing behavior first. The client's statement, "Kiss me baby! You know you want to!" is suggestive and inappropriate in a professional healthcare setting. It indicates a lack of understanding or disregard for appropriate social boundaries and may be a manifestation of the client's serious mental illness.
A, B, D- While the client's vital signs (blood pressure, heart rate, respiratory rate, and temperature) and clothing choice (wearing a heavy coat and scarf in warm weather) may be important to assess and address, the immediate priority is to address the client's inappropriate behavior and ensure a safe and therapeutic environment for both the client and the nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Childhood experiences of physical abuse, such as being hit with fists by a parent, can significantly contribute to the development of aggressive behaviors later in life. Research has shown that individuals who have experienced physical abuse during childhood are at increased risk of displaying aggression towards others, including their partners and children, as adults.
A. This statement is less directly related to the client's own experiences of aggression and may not necessarily contribute directly to their current behavior.
C. and D do not directly address experiences of violence or abuse and are less likely to contribute directly to the client's aggressive behavior towards their partner and child.
Correct Answer is D
Explanation
D. Considering an individual's learning style is essential for tailoring instruction to meet the needs and preferences of the learner. Matching instruction to learners' preferred styles can help improve their ability to receive, process, remember, and apply the information they have learned.
A. The psychomotor domain of learning refers to the development of physical skills and coordination, not thought processes.
B. Learners actively engage in the learning process by participating, asking questions, and applying new knowledge or skills.
C. Learning theories encompass various factors that influence the learning process, including the individual's cognitive processes, social interactions, and the learning environment.
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