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 Primary prevention aims to prevent the onset of a disease or health condition before it occurs. In the context of sexually transmitted infections (STIs), providing education and information about safe sex practices, condom use, and strategies for preventing STIs constitutes primary prevention efforts.
A. Secondary prevention involves early detection and intervention to prevent the progression of a disease or health condition. Examples include screening for STIs and providing prompt treatment to individuals who test positive.
C. Tertiary prevention focuses on managing and reducing the impact of existing disease or health conditions and preventing complications or disability. In the context of STIs, tertiary prevention efforts may include providing ongoing medical care, support, and education to individuals living with STIs
D. Quaternary prevention aims to mitigate or avoid the consequences of unnecessary or excessive healthcare interventions and to protect individuals from overmedicalization. It focuses on promoting prudent and ethical healthcare practices.
Correct Answer is C
Explanation
C. This statement suggests that the adolescent client lacks a supportive network or resources to discuss their problems, which can be concerning given their history of depression and suicidal ideation. It indicates a potential lack of social support, which is crucial for individuals struggling with mental health issues.
A. This statement indicates a positive behavior change, as the client has refrained from using drugs for a significant period.
B. Engaging in recreational activities and social interactions, such as participating in a dance program, can be beneficial for mental health and well-being.
D. This statement suggests that the client may be experiencing academic difficulties or stress related to missing classes. While missing classes can be concerning, the client's acknowledgment of the situation and intention to catch up may indicate a proactive approach to addressing academic challenges.
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