A nurse is caring for several clients who have mental health disorders at an assisted-living facility. Which of the following clients should the nurse determine needs to be seen by a provider immediately?

A client who is taking thioridazine and has daytime drowsiness

A client who is taking olanzapine and experiences dizziness when first standing up

A client who is taking clozapine, and has flu-like manifestations

A client who is taking chlorpromazine and reports vomiting twice

Answer and Explanation

The Correct Answer is C

A. Thioridazine and drowsiness
A common side effect, not urgent.

B. Olanzapine and dizziness
Orthostatic hypotension-monitor, but not emergent.

C. Clozapine and flu-like symptoms
Could indicate agranulocytosis, a life-threatening condition-requires immediate evaluation.

D. Chlorpromazine and vomiting
Requires monitoring, but not as urgent as option C.

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Correct Answer is ["A","B","C"]

Explanation

A. Monitoring volume status
Maintaining adequate fluid balance prevents hypotension and cerebral hypoperfusion, which can worsen ICP.

B. Ensuring proper ventriculostomy transducer levels
Accurate positioning of the transducer at the level of the foramen of Monro (tragus of the ear) ensures valid ICP readings.

C. Managing sedation
Sedation can reduce cerebral metabolism and help control ICP, especially in agitated patients.

D. Completing hourly endotracheal suctioning
Frequent suctioning increases ICP and should only be done as needed with pre-oxygenation.

E. Elevating the head of the bed 15°
The head of the bed should be elevated 30° (not 15°) to promote venous drainage from the brain and reduce ICP.

A. Gently place a hand on the client's arm during conversation. B. Employ active listening skills when communicating with the client. C. Administer an anxiolytic medication to the client. D. Explain the expected behavioral limits to the client. E. Assist the client to identify the source of anger.

Correct Answer is ["B","C","D","E"]

Explanation

A. Gently place a hand on the client's arm during conversation
Avoid touching an anxious or potentially aggressive client-may escalate agitation.

B. Employ active listening skills
Validates feelings and promotes therapeutic communication.

C. Administer an anxiolytic medication
Client is showing signs of withdrawal and agitation-medication may be indicated.

D. Explain behavioral limits
Setting limits provides structure and promotes safety.

E. Assist in identifying source of anger
Supports emotional processing and de-escalation.

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A nurse is caring for several clients who have mental health disorders at an assisted-living facility. Which of the following clients should the nurse determine needs to be seen by a provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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