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 D
Explanation
D. Mental illness is complex and multifactorial, and the response to medication can vary widely among individuals. While medication can be effective in alleviating symptoms for many people, factors such as genetic predisposition, neurobiological differences, environmental influences, and individual variability in brain function and structure can all impact treatment response.
A. While medication adherence is important for managing mental illness, it is rarely a cure on its own. Mental illness often requires ongoing treatment and management.
B. Some individuals may experience rapid improvement with medication, while others may take longer to see results or may require adjustments to their treatment plan.
C. Mental illness is not solely determined by willpower, and implying that it is oversimplifies the complex nature of these conditions.
Correct Answer is D
Explanation
D. Tardive dyskinesia (TD) is a side effect of long-term use of first-generation antipsychotic medications, such as those commonly used to treat schizophrenia. It is characterized by involuntary, repetitive movements of the face, tongue, lips, and other parts of the body.
A. Impaired ability to regulate body temperature is more commonly associated with conditions such as heatstroke or certain neurological disorders affecting the hypothalamus, and it typically presents with symptoms such as fever or hypothermia.
B. Extrapyramidal symptoms encompass a range of movement disorders caused by dysfunction of the extrapyramidal system, which includes the basal ganglia.
C. Neuroleptic malignant syndrome (NMS) is a rare but potentially life-threatening side effect of antipsychotic medications, characterized by fever, altered mental status, muscle rigidity, and autonomic dysfunction.
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