A nurse on an inpatient mental health unit is caring for a client.
The nurse is discussing the assessment findings on day 3 of admission during the 1900 change of-shift report. For each finding, specify whether the finding indicates potential improvement in or worsening of the client’s condition.
Giving away car
Hygiene
Food intake
Condition of skin on right hand
Rapid change in mood
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}
Indicates potential Improvement a. Hygiene b. Food intake c. Rapid change in mood
Indicates potential worsening a. Giving away car b. Condition of skin on right hand
Choice A: Giving away car
This could be a sign of the client’s worsening condition. Giving away possessions can sometimes be a sign of suicidal ideation. It’s important to monitor this behavior and report it to the healthcare provider.
Choice B: Hygiene
The client showered without prompting on the third day, which is an improvement from the first day when they declined to shower. Improved personal hygiene can be a sign of improvement in a client with obsessive-compulsive disorder.
Choice C: Food intake
The client ate 75% of their meals on the third day, which is an improvement from the first day when they refused to eat. Increased food intake can indicate an improvement in the client’s condition2.
Choice D: Condition of skin on right hand
The client’s hands remain reddened with a 1 cm x 1 cm area of peeling skin noted on the center of the right palm. This could indicate a worsening condition, as it may be a result of excessive handwashing, a common compulsion in OCD.
Choice E: Rapid change in mood
The client’s affect rapidly changed throughout the afternoon and early evening; the client is now talkative and appears content. This could indicate an improvement in the client’s condition, as they are engaging more with others and showing more positive emotions.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: While stress reduction techniques are important, they are not the immediate priority when a client is currently being aggressive.
Choice B reason: Role modeling is a long-term strategy and not appropriate for immediate intervention during an aggressive incident.
Choice C reason: This is the priority action to assess the risk of harm to others and to take necessary steps to ensure safety for all clients in the facility.
Choice D reason: Making a list is a reflective activity that may be part of a treatment plan but is not the priority action during an episode of aggression.
Correct Answer is B
Explanation
Choice A reason: While sharing personal experiences can sometimes help in connecting with the grieving individual, it may also shift the focus away from the partner's feelings to the nurse's own experiences. It's important to keep the conversation centered on the partner's emotions and support needs.
Choice B reason: This response acknowledges the partner's feelings without judgment and opens the door for further conversation. It shows empathy and understanding, which are crucial in providing emotional support to someone who is grieving.
Choice C reason: Suggesting a grief counselor is a practical step, but it might be perceived as dismissive if offered too quickly. It's essential to first establish a supportive dialogue and understand the partner's readiness to seek additional help.
Choice D reason: Telling someone they shouldn't feel guilty can invalidate their feelings. Guilt is a common emotion in the grieving process, and it's important to acknowledge it and provide a safe space for the individual to express their feelings.
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