A nurse is caring for a client who requires crisis intervention for acute anxiety. Which of the following nursing actions is the highest priority?

Identifying the client's coping skills.

Protecting the client from injury to himself.

Determining the cause of the client's anxiety.

Ensuring that the client feels safe.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Identifying the client's coping skills is an important assessment, but in the context of acute anxiety requiring crisis intervention, immediate safety takes precedence over assessment. Coping skills assessment can follow once the client is stable.

Choice B rationale:

Protecting the client from injury to himself is the highest priority in this scenario. Acute anxiety can lead to behaviors that pose a risk to the client's safety, such as self-harm or suicide. Ensuring the client's physical safety is paramount.

Choice C rationale:

Determining the cause of the client's anxiety is relevant for long-term care but not the immediate priority during crisis intervention. Immediate safety concerns must be addressed first.

Choice D rationale:

Ensuring that the client feels safe is important, but physical safety takes precedence. The client's subjective feeling of safety may not necessarily prevent them from engaging in harmful behaviors.

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Correct Answer is B

Explanation

Choice A rationale:

Current rehabilitation for opiate addiction is not typically associated with Wernicke-Korsakoff syndrome. Wernicke-Korsakoff syndrome is primarily linked to chronic alcohol abuse and thiamine deficiency.

Choice B rationale:

A personal history of alcohol use disorder is directly associated with Wernicke-Korsakoff syndrome. This syndrome is caused by thiamine (Vitamin B1) deficiency, which is commonly seen in individuals who have a history of heavy and chronic alcohol consumption.

Choice C rationale:

Undergoing current treatment for HIV is not a typical factor associated with the development of Wernicke-Korsakoff syndrome. This syndrome's primary cause is thiamine deficiency resulting from alcohol misuse.

Choice D rationale:

Family history of Alzheimer's disease is not a characteristic linked to Wernicke-Korsakoff syndrome. These two conditions have different etiologies and clinical presentations. Wernicke-Korsakoff syndrome is caused by thiamine deficiency, while Alzheimer's disease is a neurodegenerative disorder.

A. Brief Patient Health Questionnaire (Brief PHQ). B. Scale for Assessment of Negative Symptoms (SANS). C. Mental status examination (MSE). D. Abnormal Involuntary Movements Scale (AIMS).

Correct Answer is C

Explanation

Choice A rationale:

The Brief Patient Health naire (Brief PHQ) is primarily used for assessing the presence and severity of depressive symptoms and not specifically for cognitive disorders. It consists of nine items that assess the frequency of specific symptoms over the past two weeks.

Choice B rationale:

The Scale for Assessment of Negative Symptoms (SANS) is a tool used to assess negative symptoms in schizophrenia and other related psychotic disorders. It includes items related to affective blunting, alogia, anhedonia, and avolition, which are not directly relevant to the assessment of cognitive disorders.

Choice C rationale:

The Mental Status Examination (MSE) is a comprehensive assessment of cognitive function, including orientation, memory, attention, language, and executive function. It provides valuable information about the client's cognitive abilities and can aid in diagnosing cognitive disorders such as dementia or delirium.

Choice D rationale:

The Abnormal Involuntary Movements Scale (AIMS) is used to assess the presence and severity of tardive dyskinesia, a movement disorder commonly associated with the use of antipsychotic medications. It is not relevant to the assessment of cognitive disorders.

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A nurse is caring for a client who requires crisis intervention for acute anxiety. Which of the following nursing actions is the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting a health history on a client who has a diagnosis of Wernicke-Korsakoff syndrome. The nurse recognizes that which of the following is an expected history associated with Wernicke-Korsakoff syndrome?

Correct Answer is B

Explanation

A nurse is admitting an older adult client to the unit who has a suspected cognitive disorder. Which of the following inventories should be included as part of the admission assessment?

Correct Answer is C

Explanation

A nurse in the Emergency Department is caring for a client with symptoms of depression and admits to thoughts of self-harm with a plan. The client has a history of borderline personality disorder, depression, and substance abuse. Which of the following is the priority action by the nurse?

A nurse on a mental health unit observes a diagnosed schizophrenic patient on antipsychotics having an impaired gait and uncontrollable tremors. The nurse should recognize that which of the following adverse effects may be occurring?

A nurse in the acute mental health unit is admitting a new client with an eating disorder. The nurse is aware that which of the following are considered comorbidities of eating disorders? (Select all that apply.)

A nurse on an inpatient eating disorders unit is caring for a client who has anorexia nervosa and has a body mass index of 17.2. Which of the following actions should the nurse take? (Select all that apply.).

A nurse is caring for an older adult client who was alert and oriented at admission but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?

A nurse is providing teaching to a client diagnosed with schizophrenia and is prescribed haloperidol (Haldol). Which of the following information should the nurse include in the teaching?

A nurse is taking care of a client who has generalized anxiety disorder and is taking buspar (Buspirone). Which of the following adverse effects should the nurse report to the provider?

A nurse is caring for a client who has bipolar disorder. Which of the following actions by the client should the nurse interpret as displaying manic behavior? (Select all that apply.).