An adult client presents to the community mental health center accompanied by the client’s spouse who reports that the client has been acting impulsively. The client has spent a large amount of money lately, made several last-minute decisions to take trips, sleeps only 2 to 4 hours a night, and has lost 33 pounds (15 kg) in the last 2 months. Which nursing problem has the greatest nursing priority?

Sleep deprivation related to state of hyperactivity.

Ineffective coping related to biochemical changes.

Risk for self-directed violence related to impulsive behavior.

Imbalanced nutrition related to caloric expenditure.

Answer and Explanation

The Correct Answer is C

A.   While sleep deprivation is a concern, the client's impulsive behavior poses a greater immediate risk, making "Risk for self-directed violence related to impulsive behavior" the priority.
B.   Ineffective coping may be a contributing factor, but the risk of self-directed violence takes precedence as the primary concern.
C. The client's impulsive behavior increases the risk of self-directed violence, making it the most urgent nursing priority.
D.   Imbalanced nutrition is a concern, but the immediate risk of self-directed violence requires more immediate attention.

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Correct Answer is B

Explanation

A. Showing the client the unit may be overwhelming and not address the immediate need for communication and building rapport.
B. Explaining the nurse's role helps establish trust and provides the client with information about who is present and their purpose.
C. Reading the client his/her rights is important but may be premature and not as immediately relevant as establishing communication.
D. Offering medication should come after establishing communication and assessing the client's needs, as not all clients may require or be ready for medication.

A. Inform unlicensed assistive personnel (UAP) that the client will likely complain of a sore throat and fever. B. Place the client in protective isolation for the first two weeks of treatment with this medication. C. Offer this medication to the client with food to decrease the possibility of gastric upset. D. Report findings from the client’s weekly white blood cell (WBC) counts to the healthcare provider.

Correct Answer is D

Explanation

A. While sore throat and fever can be potential side effects of clozapine, informing UAP is not a proactive intervention. Regular monitoring of white blood cell (WBC) counts is crucial for
detecting clozapine-induced agranulocytosis.
B. Protective isolation is not a standard practice for clients taking clozapine. Monitoring for specific side effects, such as agranulocytosis, is more important.
C. Offering clozapine with food is not a priority intervention for managing potential side effects.
Monitoring and reporting WBC counts take precedence.
D. Clozapine is associated with the risk of agranulocytosis. Regular monitoring of WBC counts is essential, and any findings outside the normal range should be promptly reported to the
healthcare provider.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the nurse implement first?

Correct Answer is B

Explanation

A client is admitted to an inpatient psychiatric unit, and the antipsychotic medication clozapine is prescribed. Which intervention should the nurse include in this client’s plan of care?

Correct Answer is D

Explanation

An adolescent female with an eating disorder is admitted to the in-patient psychiatric unit. Which intervention should the nurse implement?

A client with generalized anxiety disorder (GAD) receives a new prescription for lorazepam. Which statement provided by the client requires additional instruction by the nurse?

The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued?

The nurse completes an assessment of a client experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?

After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping both feet while pacing the hallway. Which action should the nurse take?

A male client with schizophrenia continues to talk to others on the mental health unit using tangential speech. What intervention should the nurse implement?

A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. Which action should the nurse implement first?