A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

A client who is taking lithium and reports weight gain

A client who has bipolar disorder and is speaking loudly

A client who has schizophrenia and is experiencing olfactory hallucinations

A client who is taking clozapine and reports a sore throat

Answer and Explanation

The Correct Answer is D

Clozapine is an antipsychotic medication that can cause agranulocytosis, a potentially life-threatening condition that reduces the number of white blood cells and increases the risk of infection. A sore throat is a sign of infection and should be reported immediately. The other clients are not in immediate danger and can be seen later.

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Correct Answer is B

Explanation

A. Stop the newly licensed nurse from administering the medication – While it is important to prevent the administration of medication against the client's will, the focus should initially be on de-escalation to address the client's refusal.

B. Demonstrate how to verbally de-escalate the situation – This is the most appropriate first action. De-escalation techniques can help calm the client and create a dialogue, potentially leading to a willingness to discuss the medication and its benefits.

C.discussing the medication's purpose, is also secondary to honoring the client's current refusal.

D.assessing the need for restraints, would be inappropriate without first stopping the medication administration and could escalate the situation. Therefore, the first and most critical action is to stop the medication administration.

A. The client gives away some of the partner's belongings. B. The client expresses feelings of guilt. C. The client relocates from a house to an apartment. D. The client is unable to perform basic hygiene tasks.

Correct Answer is D

Explanation

A maladaptive grief response is one that interferes with normal functioning or causes significant distress for the bereaved person. The client who is unable to perform basic hygiene tasks is showing signs of depression and impaired self-care, which indicate a maladaptive grief response. The other behaviors are not necessarily maladaptive, but may reflect normal coping strategies or adjustments after losing a partner.

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A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

A home health nurse visits a client who lost their partner 2 years ago. Which of the following behaviors by the client indicates a maladaptive grief response?

Correct Answer is D

Explanation

A nurse is caring for a client who has anorexia nervosa. Which of the following findings requires immediate intervention by the nurse?

A nurse in a long-term care facility is caring for a client. The nurse should identify that which of the following conditions places the client at an increased risk for developing delirium?

A nurse is assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on a pass during lunchtime. Which of the following assessments should the nurse perform?

A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. The nurse should monitor the client for which of the following manifestations?

A nurse is caring for a client who has a binge eating disorder. Which of the following actions should the nurse take?

A nurse in a mental health facility is caring for a client who is being aggressive toward other clients. Which of the following actions is the priority for the nurse to take?

A nurse is caring for a client who has schizophrenia. The client's employer calls to discuss the client's condition. Which of the following is the appropriate nursing action?