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 D
Explanation
D. Alcohol withdrawal is characterized by a range of symptoms that can vary in severity. Some common symptoms include increased heart rate (tachycardia), sweating, tremors, anxiety, nausea, vomiting, and agitation.
A. Alcohol withdrawal is more commonly associated with increased blood pressure rather than decreased blood pressure. Nausea can be a symptom of alcohol withdrawal, particularly in the early stages, but it is not necessarily a defining characteristic.
B. Constipation and pupil constriction are not typically associated with alcohol withdrawal. These symptoms are more commonly seen with opioid withdrawal.
C Bone and muscle aches are common symptoms of alcohol withdrawal. They can occur as a result of the body's reaction to the sudden cessation of alcohol intake and the associated changes in neurotransmitter levels.
Correct Answer is A
Explanation
A. Individuals with borderline personality disorder (BPD) often experience intense and unstable emotions, impulsivity, and difficulties in regulating their emotions and behaviors. As a result, transitions, such as being discharged from the hospital, can be particularly challenging and may increase the risk of self-harm or suicidal behavior.
B. While dialectical behavior therapy (DBT) is an evidence-based treatment for BPD and focuses on teaching coping skills to manage emotions and reduce self-harming behaviors, attending therapy sessions may actually decrease the risk of self-harm for individuals actively participating in treatment.
C. Narrative therapy is another therapeutic approach that focuses on helping individuals reframe their life stories and experiences. While narrative therapy may be beneficial for some aspects of BPD treatment, it may not specifically address the immediate risk factors for self-harm.
D. Getting married may be a significant life event that brings about both positive and negative emotions, but it does not inherently indicate the highest risk for self-harm in individuals with BPD.
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