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 A
Explanation
A. describes secretive behavior, which is indicative of bulimia nervosa.
B. It suggests laxative misuse, which can be a compensatory behavior associated with bulimia nervosa. However, it does not directly address the binge-purge cycle or the emotional aspect of the behavior.
C. This describes behavior more characteristic of anorexia nervosa rather than bulimia nervosa. Anorexia nervosa involves restrictive eating behaviors and a distorted body image, whereas bulimia nervosa typically involves binge eating episodes followed by compensatory behaviors.
D. This feeling of euphoria or emotional relief during binge-purge episodes is not commonly reported by individuals with bulimia nervosa.It is mostly a complusion that bring remorse afterwards.
Correct Answer is C
Explanation
C. Dissociative amnesia is characterized by difficulty remembering important personal information, typically of a traumatic or stressful nature, that is inconsistent with ordinary forgetting. The manifestation of guilt is common in individuals experiencing dissociative amnesia, as they may feel guilty about their inability to recall events or about any actions that occurred during the period of amnesia.
A. Hallucinations involve perceiving sensations that are not present in reality, such as hearing voices or seeing things that others do not. While hallucinations can occur in various psychiatric disorders, they are not a typical manifestation of dissociative amnesia.
B. Delusions are false beliefs that are firmly held despite evidence to the contrary. Like hallucinations, delusions can occur in various psychiatric disorders, but they are not characteristic of dissociative amnesia.
D. Anhedonia refers to a reduced ability to experience pleasure or interest in previously enjoyable activities. It is not directly related to dissociative amnesia.
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