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 C
Explanation
C. This statement suggests that the adolescent client lacks a supportive network or resources to discuss their problems, which can be concerning given their history of depression and suicidal ideation. It indicates a potential lack of social support, which is crucial for individuals struggling with mental health issues.
A. This statement indicates a positive behavior change, as the client has refrained from using drugs for a significant period.
B. Engaging in recreational activities and social interactions, such as participating in a dance program, can be beneficial for mental health and well-being.
D. This statement suggests that the client may be experiencing academic difficulties or stress related to missing classes. While missing classes can be concerning, the client's acknowledgment of the situation and intention to catch up may indicate a proactive approach to addressing academic challenges.
Correct Answer is C
Explanation
C. ACEs stands for Adverse Childhood Experiences. It refers to potentially traumatic events that occur during childhood, such as physical, emotional, or sexual abuse, neglect, or household dysfunction. ACES have been linked to negative health and social outcomes later in life.
A. The SE model typically refers to the Supported Employment model, which is an evidence- based approach used to help individuals with mental illness find and maintain competitive employment.
B. SMI stands for Serious Mental Illness. It refers to mental health disorders that significantly impair an individual's ability to function in daily life.
D. MLPS does not correspond to a recognized term or acronym commonly used in healthcare or social services contexts. It is likely not relevant to the scenario described in the question.
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