A nurse working in a mental health facility is admitting a client.

Exhibits

A nurse is assisting with initiating the client's plan of care. Complete the following sentence by using the list of options (Separate using a comma).

The nurse should first address the client's
dropdown
followed by the client's
dropdown

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

The nurse should first address the client's cardiac status followed by the client's Nutritional status

Explanation:

Cardiac status: Potassium levels are critically low, which can significantly impact cardiac function.
Nutritional status: The client has multiple electrolyte imbalances, which could be related to nutrition or absorption issues.

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Correct Answer is C

Explanation

A. Elevated heart rate is not a typical sign of opioid toxicity. Opioids usually have a depressant effect on the cardiovascular system, leading to bradycardia.

B. Hypertension is not a typical effect of opioid toxicity. Opioids often cause hypotension due to vasodilation.

C. Pupillary constriction (miosis).
Acute fentanyl toxicity is associated with opioid overdose, and opioids typically cause miosis (constriction of the pupils). Other common symptoms of opioid toxicity include respiratory depression, sedation, and potentially unconsciousness.

D. Tachypnea is not a typical sign of opioid toxicity. Opioids tend to depress the respiratory system, leading to respiratory depression and potentially hypoventilation.

A. Neologism B. Clang association C. Echolalla D. Word salad

Correct Answer is A

Explanation

A. Neologism.
Neologism is a language disturbance in which the individual creates new, idiosyncratic words that have meaning only to the individual. In this case, the client's use of "mazuka" is an example of a neologism as it is a made-up word that holds significance only for the client.

B. Clang association involves the association of words based on sound rather than meaning.

C. Echolalia is the repetition of words or phrases spoken by others.

D. Word salad refers to a jumble of words and phrases that lack coherent meaning or logical connection.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has been brought to the emergency department and is experiencing acute fentanyl toxicity. The nurse should expect to observe which of the following adverse effects in this client?

Correct Answer is C

Explanation

A nurse overhears a client who has schizophrenia talking to herself. The client keeps stating "The muxtranks are coming. The muntranks are coming. The nurse correctly recognizes the client's use of the word mazuka as an example of which of the following alterations in speech?

Correct Answer is A

Explanation

A nurse is caring for a client who has paranoid schizophrenia and a new prescription for risperidone. The client asks the nurse what the s is supposed to do. Which of the following responses should the nurse make?

A nurse in an acute care mental health facility is contributing to the plan of care for a client who is newly diagnosed with schizophrenia and is verbalizing paranoid delusions. Which of the following interventions should the nurse include in the plan?

A nurse is talking with a client who has schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, "I'm feeling sad. I don't want to talk now." Which of the following responses should the nurse make?

A nurse is caring for a client who has a serious mental illness and has developed tardive dyskinesia from anti-psychotic medication use. Which of the following adverse effects from anti-psychotic medication use would be expected for the client?

A nurse is caring for a client who reports a state of increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate response by the nurse?

A nurse is caring for a client who is experiencing acute mania. Which of the following actions should the nurse take?