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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This response acknowledges the client's concerns and invites further discussion about their experience. The nurse can use this information to assess the severity and duration of the client's symptoms, as well as any potential triggers or stressors that may be contributing to their anxiety and inability to concentrate.
Option a "Have you talked to your friends about this yet?" may not be an appropriate response, as the client may need more professional support than what their friends can provide.
Option b "I have problems too, everybody has problems" may be dismissive of the client's concerns and may not help them feel heard or understood.
Option d "Have you talked to your parents about this yet?" may not be an appropriate response, as the client may not feel comfortable discussing their concerns with their parents or may need more professional support than what their parents can provide.
Option e "Why do you think you are so anxious?" may be seen as confrontational and may not help the client feel heard or understood.
Option f "It sounds like you're having a difficult time" acknowledges the client's concerns but does not invite further discussion or provide an opportunity for the nurse to gather more information.
Correct Answer is B
Explanation
This response acknowledges the client's distress and opens the opportunity for the client to express their feelings and concerns. It also demonstrates empathy and a willingness to listen, which can help deescalate the situation and build trust between the nurse and client.
Option a ("Others are being distracted; Please, quiet down and go to your room") is dismissive of the client's feelings and may further escalate the situation.
Option c ("Please go to your room to get control of yourself") is directive and may be perceived as confrontational, potentially increasing the client's agitation.
Option d ("What's going on? Be quiet") is insensitive and dismissive of the client's distress and may further agitate the client.
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