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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. This promotes accountability by involving an identified support person in the client's exercise plan. Sharing the exercise log with a support person creates a sense of responsibility and encouragement for the client to adhere to their exercise regimen. Knowing that someone else will review their progress can motivate the client to stay committed to their goals and maintain consistency in their exercise routine.
A. Setting a specific duration for daily exercise is a good goal-setting strategy. However, it does not inherently provide a mechanism for accountability. The client may not feel as motivated to adhere to the exercise plan consistently.
B. This option involves client engagement and preference, which is important for promoting adherence to an exercise routine. However, it does not directly address accountability.
C. Setting a specific timeframe for daily exercise is another goal-setting strategy, but without mechanisms for accountability, the client may struggle to maintain consistency.
Correct Answer is C
Explanation
C. Agranulocytosis is a serious side effect associated with clozapine, an antipsychotic medication. Agranulocytosis is characterized by a severe reduction in the number of white blood cells (specifically granulocytes) in the bloodstream, leading to an increased risk of infection. The client should be educated to monitor for signs and symptoms of agranulocytosis, including sore throat, fever, chills, and muscle aches, as these may indicate an underlying infection due to neutropenia.
A. Severe restlessness may be a side effect of some antipsychotic medications, but it is not specifically associated with agranulocytosis.
B. Respiratory depression and a comatose state are not typical manifestations of agranulocytosis.
D. Increased anxiety and suicidal ideations may be symptoms of certain mental health conditions or adverse effects of psychiatric medications, but they are not characteristic of agranulocytosis.
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