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

Choice A reason:

Obtaining the provider's prescription within 60 min is not the immediate action required in this scenario. The priority is to ensure the safety of the client and others, which is achieved by continuous monitoring and documentation.

Choice B reason:

Documenting the client's behavior every 15 min is crucial in managing physically aggressive clients in seclusion. This allows the healthcare team to monitor the client's condition closely and make necessary interventions promptly.

Choice C reason:

Monitoring the client's vital signs every 4 hr may not be frequent enough for a client in seclusion who has been physically aggressive. The client's condition could change rapidly, and more frequent monitoring might be necessary.

Choice D reason:

Offering food and fluids every 2 hr is important for maintaining the client's physical health, but it is not the primary action in managing a physically aggressive client in seclusion. The immediate focus should be on ensuring safety and managing the client's aggressive behavior.

A. Edema B. Heart rhythm C. Temperature D. Intake

Correct Answer is B

Explanation

A client who has anorexia nervosa is at risk for cardiac arrhythmias due to electrolyte imbalances, dehydration, and malnutrition. The client's statement of feeling their heart jumping in their chest indicates a possible irregular heartbeat that should be reported to the provider. Edema, temperature, and intake are not as urgent as heart rhythm in this case.

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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 has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

A nurse is caring for a client who has Alzheimer's disease. Which of the following findings should the nurse expect?

A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?

A home health nurse is caring for a client who is in the continuation phase of major depressive disorder. The client states, "I feel unmotivated and don't feel like leaving my home." Which of the following recommendations should the nurse make to address the client's social isolation?

A nurse is caring for a client who has an anxiety disorder and is scheduled for a procedure. The client informs the nurse that they do not want to have the procedure. Which of the following actions should the nurse take?

A nurse is reviewing the medication administration record of a client who has major depressive disorder and a new prescription for selegiline. The nurse should recognize that which of the following client medications is contraindicated when taken with selegiline?

A nurse is caring for a client who has borderline personality disorder and has been engaging in self-mutilation. The nurse should encourage the client to participate in which of the following groups?

A nurse is assessing a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms of schizophrenia? (Select all that apply.)