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 B

Explanation

The nurse's priority is to ensure that the child is safe and protected from further harm. A spiral fracture is a type of fracture that occurs when a bone is twisted, and it is often associated with child abuse. The nurse should assess if there are any other signs of abuse, such as bruises, burns, or cuts, and if there are any threats to the child's well-being at home or elsewhere. The nurse should also provide emotional support and comfort to thechild. The other options are important steps to take, but they are not as urgent as ensuring safety.

A. Impaired memory B. Inappropriate speech patterns C. Command hallucinations D. Rapid mood swings

Correct Answer is C

Explanation

Command hallucinations are auditory hallucinations that instruct the client to perform an action, such as harming oneself or others. This is a medical emergency that requires immediate intervention by the nurse to ensure safety and prevent harm.

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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

A nurse in a provider's office is assessing a school-age child who has a spiral fracture. The parent of the child provides different accounts of the cause of the injury. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is assessing a client who has delirium. Which of the following findings requires immediate intervention by the nurse?

Correct Answer is C

Explanation

A nurse is preparing for an interprofessional team meeting regarding a newly admitted client who has major depressive disorder. Which of the following findings obtained during the initial assessment is the priority to report to other disciplines?

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A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?

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A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?