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 C
Explanation
Manipulative behavior is not acceptable in any situation, and it is important for the nurse to set clear boundaries and expectations with the client. Allowing manipulation can enable the client's behavior and reinforce it. Avoiding discussing past or present manipulative behaviors with the client may not effectively address the issue and could potentially worsen the behavior. Bargaining with the client can also reinforce manipulative behavior.
Therefore, instituting consequences for manipulative behavior is the most appropriate intervention to include in the plan of care. This could involve setting clear limits on what is acceptable behavior and consistently enforcing consequences when those limits are exceeded. The consequences should be communicated clearly to the client, and the nurse should work with the client to identify more appropriate ways to communicate their needs and concerns.
Correct Answer is ["A","E"]
Explanation
a. “I can see that you feel sad about this situation”.
e. “The loss of your parent should be very painful for you.”
These responses by the nurse show empathy and validate the patient’s feelings. They also encourage the patient to continue expressing their emotions and facilitate communication.
Option b. “Don’t be sad, everyone has to pass for something like this in the life” is not a helpful response
because it minimizes the patient’s feelings and may make them feel like their emotions are not valid.
Option c. “I felt very sad when my mother died, it was horrible!” is not a helpful response because it shifts the focus of the conversation away from the patient and onto the nurse’s personal experience.
Option d. “Let’s talk about something else. this subject is upsetting you, don’t worry about this” is not a helpful response because it dismisses the patient’s emotions and may make them feel like they are not allowed to express their feelings.
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