An adult patient assaulted another patient and was subsequently restrained. One hour later, which statement by the restrained patient requires the nurse’s immediate attention?
“The other patient started the fight.”.
“I hate all of you.”.
“My fingers are tingling.”.
“You wait until I tell my lawyer.”.
The Correct Answer is C
Choice A rationale
While it’s important to understand the circumstances leading to the assault, this statement does not require immediate attention from the nurse. It’s more related to the incident itself rather than the patient’s current condition.
Choice B rationale
Expressing hatred towards others can be a sign of emotional distress, but it does not require immediate medical attention.
Choice C rationale
Tingling in the fingers can be a sign of reduced blood circulation, which could be a result of the restraints. This requires immediate attention to prevent further complications.
Choice D rationale
While it’s important to address legal threats, this statement does not require immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Hypertensive crisis is a severe increase in blood pressure that can lead to a stroke. The symptoms of a hypertensive crisis can include a severe headache, nausea, and vomiting, but not typically dry mouth and constipation.
Choice B rationale
Increased prolactin levels in the bloodstream can cause symptoms such as breast enlargement, production of breast milk, and menstrual changes, but not typically dry mouth and constipation.
Choice C rationale
Central nervous system stimulation can cause symptoms such as restlessness, insomnia, and tremors, but not typically dry mouth and constipation.
Choice D rationale
Anticholinergic reactions can cause a wide range of symptoms, including dry mouth and constipation. These are common side effects of many medications, including Risperdal.
Correct Answer is D
Explanation
Choice A rationale
While ineffective coping related to inadequate stress management is a valid nursing diagnosis, it is not the highest priority in this situation. The client’s life is not immediately at risk due to ineffective coping.
Choice B rationale
Hopelessness related to recent divorce is a significant concern, but it is not the highest priority. The immediate threat to the client’s life is the suicidal ideation with a highly lethal plan.
Choice C rationale
Spiritual distress related to conflicting thoughts about suicide and sin is a potential nursing diagnosis for this client. However, the immediate life-threatening issue takes precedence.
Choice D rationale
Risk for suicide related to highly lethal plan is the highest priority nursing diagnosis. The client has a plan to commit suicide with a handgun, which is a highly lethal method. Immediate intervention is required to ensure the client’s safety.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.