A nurse is caring for a client whose partner died 6 months ago. Which of the following findings is the nurse's priority?

The client states that he is unable to eat more than once a day.

The client frequently recalls negative experiences that occurred during his marriage.

The client relates that he is angry that the provider did not save his partner's life.

The client says he feels guilty about not spending more time with his partner.

Answer and Explanation

The Correct Answer is A

The nurse's priority is to address the client's physical needs, such as nutrition and hydration, which are essential for survival and recovery. The client who is unable to eat more than once a day is at risk for malnutrition, dehydration, and electrolyte imbalance, which can lead to serious complications. The other findings indicate emotional distress and grief, which are also important to address, but not as urgent as the client's physical health.

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Correct Answer is A

Explanation

Significant weight loss. This finding indicates a risk for malnutrition, dehydration, and electrolyte imbalance, which can affect the client's physical and mental health. The other findings are also important to report, but they are not as urgent as weight loss.

A. Obtain the provider's prescription within 60 min. B. Document the client's behavior every 15 min. C. Monitor the client's vital signs every 4 hr. D. Offer the client food and fluids every 2 hr.

Correct Answer is B

Explanation

Choice A reason:

Obtaining the provider's prescription within 60 min is not the immediate action required in this scenario. The priority is to ensure the safety of the client and others, which is achieved by continuous monitoring and documentation.

Choice B reason:

Documenting the client's behavior every 15 min is crucial in managing physically aggressive clients in seclusion. This allows the healthcare team to monitor the client's condition closely and make necessary interventions promptly.

Choice C reason:

Monitoring the client's vital signs every 4 hr may not be frequent enough for a client in seclusion who has been physically aggressive. The client's condition could change rapidly, and more frequent monitoring might be necessary.

Choice D reason:

Offering food and fluids every 2 hr is important for maintaining the client's physical health, but it is not the primary action in managing a physically aggressive client in seclusion. The immediate focus should be on ensuring safety and managing the client's aggressive behavior.

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A nurse is caring for a client whose partner died 6 months ago. Which of the following findings is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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