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 B
Explanation
B. Trauma during the developmental years, especially in early childhood, is considered a significant risk factor for the development of DID. Trauma disrupts normal psychological development and can lead to the fragmentation of identity as a coping mechanism to dissociate from overwhelming or traumatic experiences.
A. A history of self-injurious behavior is often associated with various mental health conditions, such as borderline personality disorder, post-traumatic stress disorder (PTSD), or depression but it is not a primary risk factor for dissociative identity disorder (DID).
C. Individuals with BPD may experience dissociative symptoms, particularly during times of stress or intense emotional arousal but BPD itself is not considered a primary risk factor for dissociative identity disorder (DID).
D. Individuals with schizophrenia may experience dissociative symptoms, such as depersonalization or derealization but these symptoms are typically secondary to psychotic experiences rather than being indicative of dissociative identity disorder (DID).
Correct Answer is C
Explanation
C. It acknowledges the client's request and communicates that their request will be addressed in collaboration with their healthcare provider. This response respects the client's autonomy while also ensuring that medication decisions are made within the context of a comprehensive healthcare plan overseen by a qualified provider.
A. This statement may come across as dismissive or confrontational to the client. It does not effectively address the client's request or provide guidance on how to proceed.
B. This question may imply suspicion or judgment about the client's motives for seeking a new prescription. It does not foster open communication or collaboration between the nurse and the client and may create a barrier to effective communication.
D. This option is not the appropriate response to a request for a new medication prescription. This option does not address the client's specific request and may not be relevant to their current healthcare needs.
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