A nurse on an in-patient unit received report at 15:00 hours. Which client should the nurse see first?

A client diagnosed I with hypomania who is speaking loudly on the unit.

A client diagnosed with hypomania who is complaining of pain.

A client with a history of mania who is pacing in the hallway

A client diagnosed with mania who expressed active suicidal ideations

Answer and Explanation

The Correct Answer is D

A. A client diagnosed with hypomania who is speaking loudly on the unit: Hypomania involves elevated mood and increased activity, but it doesn't typically present an immediate risk of harm to self or others. While it may be disruptive, it doesn't have the same urgency as active suicidal ideation.

B. A client diagnosed with hypomania who is complaining of pain: Pain complaints should be addressed, but in the context of the given choices, it is not the highest priority. Assessing and addressing the potential for harm due to active suicidal ideation is more critical.

C. A client with a history of mania who is pacing in the hallway: Pacing in the hallway, while indicative of increased activity, does not necessarily indicate an immediate risk. The client expressing active suicidal ideations poses a more urgent concern that requires immediate attention.

D.A client diagnosed with mania who expressed active suicidal ideations

In determining priority, the nurse should consider the level of risk and the potential for harm to self or others. Suicidal ideation is a significant concern that requires immediate attention. A client expressing active suicidal thoughts poses an immediate risk to their safety.

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Correct Answer is A

Explanation

A. Psychosocial history:

This includes information about the client's social, cultural, family, educational, and occupational background. It provides insights into the client's life circumstances, stressors, support systems, and overall psychosocial context. This information is crucial for understanding the context in which mental health symptoms may be occurring.

B. Vaccine history:

Vaccine history is not typically a primary factor in diagnosing mental health disorders. It is more relevant to preventive care and physical health.

C. History of allergies:

Allergies are primarily related to physical health and may not play a direct role in the diagnosis of mental health disorders.

D. Surgical history:

Surgical history is relevant to physical health conditions and is not a primary consideration in the diagnosis of mental health disorders.

A. Provide client with high-calorie finger foods throughout the day B. Teach the importance of a varied diet to meet nutritional needs. C. Initiate total parenteral nutrition to meet dietary needs D. Accompany client to cafeteria to encourage adequate dietary consumption

Correct Answer is D

Explanation

A. Provide client with high-calorie finger foods throughout the day:

While providing high-calorie finger foods may increase caloric intake, it may not be the most effective strategy for a specific weight gain goal. It's essential to encourage a balanced and varied diet.

B. Teach the importance of a varied diet to meet nutritional needs:

This is a good general approach to promote overall nutritional health, but it may not be specific enough to address the immediate goal of gaining 2 pounds within a week.

C. Initiate total parenteral nutrition to meet dietary needs:

Total parenteral nutrition is an invasive and aggressive intervention typically reserved for cases where oral or enteral feeding is not possible or insufficient. It is not the first-line approach for someone who can consume food orally.

D. Accompany client to cafeteria to encourage adequate dietary consumption:

This is the most appropriate intervention. Accompanying the client to the cafeteria provides an opportunity for direct encouragement and support during meals. It helps ensure that the client is consuming an adequate amount of food, which is crucial for the goal of gaining 2 pounds within a week.

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A nurse on an in-patient unit received report at 15:00 hours. Which client should the nurse see first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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