An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam. During the health assessment, the client reports experiencing of chest pain. Which action should the nurse take first?

Refer the client to the cardiology clinic.

Obtain the client's blood pressure.

Determine if alprazolam was taken recently.

Assess the client for substance abuse.

Answer and Explanation

The Correct Answer is B

Choice A rationale: Referring the client to the cardiology clinic may be necessary, but obtaining the client's blood pressure is the priority to assess the immediate need for intervention and determine the appropriate course of action.

Choice B rationale: Obtaining the client's blood pressure is the most immediate and relevant action. Chest pain is a potentially serious symptom, and assessing blood pressure will help determine the urgency of the situation.

Choice C rationale: Determining if alprazolam was taken recently is important but may not be the immediate priority when the client is reporting chest pain. Assessing vital signs is crucial in this situation.

Choice D rationale: Assessing the client for substance abuse is relevant to the overall care of the client but may not be the immediate priority when chest pain is reported. The nurse should address potential medical emergencies first.

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Correct Answer is C

Explanation

Choice A rationale: Fear of large dogs may or may not be related to schizophrenia; other information is needed to determine its significance.

Choice B rationale: Decreased attention to detail is a symptom that may be observed in schizophrenia, but it is not the primary behavior to notify the healthcare provider.

Choice C rationale: Social withdrawal is a concerning behavior in schizophrenia that may indicate worsening symptoms and should be reported to the healthcare provider.

Choice D rationale: Changes in appetite are important to monitor but may not be the primary indicator of a worsening condition in schizophrenia.

A. Screen the client for domestic violence. B. Determine the client's risk for suicide. C. Ask client to state a chief complaint for admission. D. Obtain a baseline set of vital signs.

Correct Answer is D

Explanation

Choice A rationale: Screening the client for domestic violence requires a more comprehensive assessment and interpretation of findings, which is beyond the scope of practice for the UAP.

Choice B rationale: Determining the client's risk for suicide involves complex judgment and should be assessed by a licensed healthcare provider, not a UAP.

Choice C rationale: Asking the client to state a chief complaint for admission involves initial communication and assessment skills, which should be performed by licensed nursing staff.

Choice D rationale: Obtaining a baseline set of vital signs is a routine task that can be delegated to the UAP. It is a non-complex and standard part of the admission process.

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An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam. During the health assessment, the client reports experiencing of chest pain. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing teaching to a client and family about schizophrenia before discharge from an inpatient facility. The nurse should instruct the family to notify the healthcare provider when which behavior is observed?

Correct Answer is C

Explanation

The nurse is completing an admission assessment for a client with a known history of depression and multiple, unexplained fractures. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)?

Correct Answer is D

Explanation

A client who experiences memory loss is diagnosed with Wernicke encephalopathy caused by alcohol addiction. Which intervention is most important for the nurse to implement?

An 18-year-old client is brought to the emergency department with a suspected drug overdose. Which information is most important for the nurse to obtain from the family?

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The nurse interacts with a client who is very depressed and slow to respond to questions. The nurse asks the client to describe current feelings, but the client looks down at the table. Which action is best for the nurse to implement?

A client with chronic alcoholism receives a prescription for disulfiram. Which client statement indicates that this medication teaching has been effective?

A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent when the client says, "I don't know how I will go on." What is the reason for the nurse's behavior?