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 D

Explanation

D. In the immediate aftermath of a sexual assault, the primary focus of the SANE nurse is to ensure the safety and well-being of the client. This includes providing a safe and supportive environment for the client, assessing and treating any physical injuries, addressing immediate medical needs, and offering emotional support and crisis intervention.

A, B, and C involve aspects of legal procedures and involvement of law enforcement, but they may not be appropriate or feasible for every client in every situation. Additionally, the decision to involve law enforcement or pursue legal action should be made in collaboration with the client and should prioritize their safety, autonomy, and well-being.

A. Adverse effects of treatment B. Medication adherence C. Exposure to environmental allergens D. Immune system

Correct Answer is D

Explanation

D. The immune system plays a crucial role in the body's response to infections and inflammation. Research suggests that dysregulation of the immune system, including chronic inflammation and autoimmune disorders, may contribute to the development or exacerbation of certain mental health disorders.

A. Adverse effects of treatment for mental health disorders can impact the client's well-being and quality of life but they are not typically considered risk factors for developing mental illness. B Medication adherence refers to the extent to which a client follows the prescribed treatment regimen. Poor adherence does not increase the risk for mental illness

C. Allergic reactions primarily affect the respiratory or immune systems and are not typically linked to mental health outcomes.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A sexual assault nurse examiner (SANE) is a caring for a client who experienced sexual assault. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

The nurse is collecting the health history of a client and determines that the client has risk factors for developing mental illness. Which of the following should the nurse identify as a possible contributing factor in the development of a mental health disorder?

Correct Answer is D

Explanation

A nurse is providing discharge teaching to a client who has borderline personality disorder. The client reports being a single parent caring for two toddlers. Which of the following actions should the nurse take?

A nurse is caring for a client who frequently breaks their arms and other bones on purpose. The nurse understands that the client likely has which diagnosis?

A nurse is caring for a client who has asthma and allergies. The client asks the nurse about environmental influences they should avoid. The nurse should inform the client to avoid which of the following?

A nurse is discussing relapse potential with a group of clients and their families. The nurse should include which of the following statements about relapse prevention?

A nurse is preparing a presentation about strategies to decrease health care disparities among vulnerable groups. Which of the following strategies should the nurse include?

A nurse is reviewing laboratory results for a client and notes a serum lithium level of 1.6 mEq/L. Which of the following manifestations should the nurse expect the client to report?