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. This statement accurately describes a key aspect of somatic symptom disorder. Individuals with this disorder experience real physical symptoms, but these symptoms are primarily driven by psychological or emotional factors rather than underlying physical causes.
B. Suicidal ideation is not a defining characteristic of the disorder. Somatic symptom disorder primarily involves persistent and distressing physical symptoms along with excessive thoughts, feelings, or behaviors related to those symptoms.
C. Somatic symptom disorder is not characterized by malingering or intentionally fabricating symptoms. Individuals with this disorder genuinely experience physical symptoms that cause distress and impairment
D. There are effective treatment approaches available, including cognitive-behavioral therapy (CBT), psychotropic medications for co-occurring conditions such as depression or anxiety, and supportive therapies that address underlying psychological factors
Correct Answer is D
Explanation
D. Schizophrenia is typically diagnosed in young adulthood, usually in the late teens to early twenties, although it can also occur later in life. Symptoms often emerge during this period of development, characterized by disturbances in thinking, perception, emotions, and behavior.
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