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 A

Explanation

A. Advising the mother to call the police if violent behavior occurs again addresses the safety of the client and others and is a necessary step to ensure appropriate intervention.
B. Referring the mother for psychiatric evaluation is important but may not directly address the immediate safety concern related to the recent violent behavior.
C. Reinforcing the need for the adolescent to attend group therapy sessions is relevant, but the immediate focus should be on addressing the safety issue.
D. Telling the mother to describe her feelings may be helpful for therapeutic communication but may not be the most urgent intervention in response to the reported violent behavior.

A. Sit in the chair next to the client. B. Listen to what the client is saying. C. Escort the client to his room. D. Administer a PRN sedative.

Correct Answer is B

Explanation

A. Sitting in the chair next to the client may be supportive but does not address the immediate concern of the client's behavior or hallucinations.
B. Listening to what the client is saying is crucial to understanding the content and nature of the auditory hallucinations, providing insight into the client's experience.
C. Escorting the client to his room may be necessary if the behavior poses a risk, but understanding the content of the hallucinations should precede immediate removal.
D. Administering a PRN sedative may be considered later based on the assessment, but understanding the nature of the hallucinations and the client's current state is the priority.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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?

Correct Answer is B

Explanation

Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?

Which individual should the nurse consider at the highest risk for suicide?

The nurse is caring for a client who is a refugee from another country and who is experiencing daily episodes of anxiety. The client communicates minimally with the nurse, looking away and appearing distressed. Which intervention is most important for the nurse to do first?

A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?

The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?

An adolescent who is exhibiting a depressed affect receives a prescription for an antidepressant drug. While the client is taking the antidepressant, which comparison of the client’s behavior before and after taking the drug is most important for the nurse to obtain?

A client with opioid dependence makes a statement to the nurse about desiring to lead a healthier lifestyle by making changes in the next 2 weeks. How should the nurse respond?

The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the client’s history should the nurse further explore?