A nurse is caring for several clients who are attending community-based mental health programs. Which Of the following clients should the nurse plan to visit first?
Select one:
A client who recently burned her arm by accident while using a hot iron at home.
A client who tells the nurse he experienced manifestations of severe anxiety before and during a job interview.
A client who requests that her antipsychotic medication be changed due to some new adverse effects.
A client that says he is hearing a voice that tells him he is not worthy of living anymore.
The Correct Answer is D
This client is experiencing auditory hallucinations and may be at risk for self-harm or suicide. The nurse should prioritize visiting this client first to assess their safety and provide appropriate interventions.
Option a. A client who recently burned her arm by accident while using a hot iron at home may require wound care and education on safety, but this situation is not as urgent as the client experiencing auditory hallucinations.
Option b. A client who tells the nurse he experienced manifestations of severe anxiety before and during a job interview may benefit from interventions to manage anxiety, but this situation is not as urgent as the client experiencing auditory hallucinations.
Option c. A client who requests that her antipsychotic medication be changed due to some new adverse effects may require medication adjustment and monitoring for side effects, but this situation is not as urgent as the client experiencing auditory hallucinations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Borderline personality disorder is a serious mental illness characterized by instability in mood, behaviour, and self-image. Patients with borderline personality disorder are at a high risk of self-harm, suicide, and impulsive behaviours. Therefore, the nurse's priority assessment should be to identify any suicidal or homicidal ideations, as these can be life-threatening emergencies. Once identified, appropriate interventions should be initiated, such as suicide precautions, crisis management, and referral to mental health professionals for further evaluation and treatment.
While sleep patern changes, impulsive behaviours, and support systems are also important aspects to assess in patients with borderline personality disorder, they are not the priority when compared to suicidal or homicidal ideations.
Correct Answer is D
Explanation
If the nurse has concerns about the prescribed dose of an antianxiety medication being higher than the usual adult dose, they should hold the medication and consult with the health care provider before administering it. This will allow the health care provider to review the prescription and make any necessary adjustments to ensure the safety and well-being of the patient.
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