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

Answer and Explanation

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.

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Correct Answer is B

Explanation

B. Borderline personality disorder (BPD) is characterized by unstable mood, behavior, and relationships, often leading to impulsive behaviors including self-harm. It's crucial for the family to understand the potential for self-harm in individuals with BPD and to learn how to recognize warning signs and effectively intervene to ensure the client's safety.

A. While medication may be a component of treatment for some individuals with BPD, it is not typically the first-line intervention for managing the disorder.

C. Group therapy, particularly dialectical behavior therapy (DBT) groups, can be beneficial for individuals with BPD as they provide opportunities for skill-buildin. However, it may not be the immediate priority when teaching the family about BPD.

D. Insurance coverage can be addressed at a later time, and the immediate focus should be on providing information and support to help the family understand and cope with the diagnosis and its implications for the client's well-being.

A. Stage 1 (mild) B. Stage 3 (severe) C. The client's manifestations indicate a psychotic disorder instead of alcohol withdrawal. D. Stage 2 (moderate)

Correct Answer is B

Explanation

Stage 3 alcohol withdrawal, also known as delirium tremens (DTs), is characterized by severe manifestations, including hallucinations (such as seeing spiders crawling on the walls), disorientation, agitation, and potentially life-threatening physiological disturbances. The client's

belief that they are at home and calling for their mother indicates significant confusion and disorientation, which are common features of delirium tremens.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching the family of a client who has a new diagnosis of borderline personality disorder about the disorder. Which of the following information should be the nurse's priority?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

A nurse is preparing to discharge a client who has been diagnosed with schizophrenia. The client asks, "I am not sure why I need to have a relapse plan." Which of the following responses should the nurse make?

A nurse is caring for a client who describes extreme fear of having or acquiring a disease. The client is also exhibiting behaviors like repeated body checking. The nurse should identify that the client is exhibiting manifestations of which of the following disorders?

A nurse is caring for a client who recently gave birth. The nurse notices the newborn is displaying manifestations of opioid withdrawal. The nurse should recognize the newborn's manifestations as signs of which of the following conditions?

A community health nurse is preparing an educational activity that addresses the domains of learning. The nurse should know that the affective domain focuses on which of the following?

A nurse is educating a client who is prescribed clozapine. Which of the following findings should the nurse identify as consistent with agranulocytosis and instruct the client to monitor?

A nurse is providing care to a client is who is recovering from an episode of dissociative amnesia. The nurse should expect the client to exhibit which of the following manifestations?

A nurse is caring for a client who has avoidant personality disorder. Which of the following types of therapy should the nurse anticipate for the client?