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. Calling the poison control center is the immediate and most important action to take in cases of potential poisoning or chemical exposure. Poison control centers have trained professionals who can provide immediate guidance on how to assess the situation, provide first aid if necessary, and determine if further medical evaluation or treatment is needed.
A. While assessing the parent's understanding of emergency measures is important, it may not be the first action to take in this situation.
B. Providing information about the risks of chemical exposure can be helpful for prevention, but it may not be the first action to take when there is uncertainty about whether the child has ingested a harmful substance.
D. While securing cleaning supplies to prevent future incidents is important, it is not the first action to take when there is concern about a potential ingestion.
Correct Answer is B
Explanation
A. While it's important to gather relevant information about the assault, asking open-ended questions about the perpetrator may not be the most appropriate approach initially.
B. Speaking softly helps to convey empathy and can make the client feel more comfortable and less threatened.
C. Direct eye contact can be perceived as intrusive or threatening, especially for individuals who have experienced trauma such as sexual assault.
D. Sitting next to the client rather than directly across can create a more relaxed and less intimidating atmosphere. This approach can help establish a sense of partnership and support, making the client feel more at ease.
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