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. Fluctuating cognition and visual hallucinations are characteristic features of Lewy body dementia (LBD). LBD is a type of dementia that involves abnormal protein deposits called Lewy bodies in the brain. These deposits can cause fluctuations in cognitive abilities, leading to periods of clarity alternating with confusion or disorientation. Visual hallucinations are also common in LBD, often involving seeing people, animals, or objects that are not present.
A. Prion diseases are not commonly associated with fluctuating cognitive function.
C. HIV infection can cause a range of neurological complications, but they usually manifest differently from the symptoms described in the scenario.
D. Symptoms of TBI-related dementia would depend on the severity and location of the brain injury, but they often involve cognitive deficits consistent with the area of brain damage
Correct Answer is C
Explanation
C. Reinforcing teaching with vulnerable clients about strategies to prevent illness and promote health is the most immediate and direct action the nurse can take. Education empowers
individuals to make informed decisions about their health and well-being, potentially preventing illness and reducing the need for healthcare services.
A. This action focuses on improving access to care but may not directly address the immediate health needs of vulnerable clients.
B. Protecting the rights and well-being of clients without housing is important, but it may take time to implement legislative changes and see the effects.
D. While advocating for policy change and advising elected officials on the needs of vulnerable populations is important for systemic change, it may not directly address the immediate health needs of vulnerable clients
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