A nurse on an acute mental health unit is assessing four clients. Which of the following clients is the highest priority?
A client who has dementia and exhibits aphasia
A client who has bipolar disorder and displays constant pacing
A client who has schizophrenia and uses neologisms
A client who has depressive disorder and has poor personal hygiene
The Correct Answer is B
A. A client who has dementia and exhibits aphasia: While aphasia can be concerning, it is not necessarily indicative of immediate risk to the client or others.
B. A client who has bipolar disorder and displays constant pacing: This client is the highest priority because constant pacing may indicate agitation or escalating anxiety, which could lead to agitation or aggression and require immediate intervention to prevent harm to the client or others.
C. A client who has schizophrenia and uses neologisms: Neologisms, although indicative of disorganized thinking, do not necessarily present an immediate safety concern compared to constant pacing.
D. A client who has depressive disorder and has poor personal hygiene: While poor personal hygiene is important to address for the client's well-being, it may not present an immediate safety risk compared to the behaviors exhibited by the client in option B.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Withdrawal of medication from an ampule should be done using a filter needle or a needle with a filter straw to prevent glass particles from being drawn into the syringe. Using a subcutaneous needle is not appropriate for this purpose and may lead to contamination or injury.
B. Breaking the top of the ampule using an antiseptic wipe is an acceptable method to access the medication within the ampule.
C. Performing 3 checks of the medication before administration is a standard safety practice to ensure the correct medication, dose, and route.
D. Disposing of the ampule by placing it in a sharps container is the correct method for safe disposal of glass ampules after use.
Correct Answer is B
Explanation
A. Instruct the AP to request assistance when unsure about a task: While this is an important instruction, the immediate priority is ensuring the safety of the client during the transfer.
B. Help the AP assist the client with the transfer: This is the correct answer. The nurse should intervene immediately to ensure the safety of the client during the transfer. Providing assistance to the AP in safely transferring the client is the most appropriate action to take first.
C. Refer the AP to the facility procedure manual: While facility procedures are important, referring to the manual may not address the immediate need to correct the incorrect transfer and ensure client safety.
D. Demonstrate the proper client transfer technique for the AP: While education and demonstration of correct techniques are important, the immediate priority is to intervene and ensure the safety of the client during the transfer.
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