The nurse is preparing to discharge a client home from a mental health institution. The nurse should recognize that in order for a mental health client to receive home-bound health care, which of the following criteria must be met?

A patient who does not have a support system at home.

A patient who is refusing to go to group therapy.

A patient with major depressive disorder and stopped taking his medication.

A patient who is unable to leave home without assistance.

Answer and Explanation

The Correct Answer is D

A. A patient who does not have a support system at home: While a lack of support is a concern, it is not a criterion for home-bound health care eligibility.

B. A patient who is refusing to go to group therapy: Refusal to participate in therapy does not meet the criteria for being home-bound.

C. A patient with major depressive disorder and stopped taking his medication: While this is a serious situation, it does not necessarily mean the patient is home-bound.

D. A patient who is unable to leave home without assistance: This fits the definition of being home-bound, which means the patient has a condition that makes leaving the home difficult and requires assistance.

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Correct Answer is B

Explanation

A. Administer diazepam: This is not a first-line treatment for delirium and could exacerbate confusion or sedation, potentially worsening delirium.

B. Obtain a medical history: Delirium is often caused by underlying medical conditions such as infections, electrolyte imbalances, or medication side effects. Obtaining a medical history is crucial for identifying and treating the underlying cause, making it the priority action.

C. Start intravenous fluids: While IV fluids might be necessary in cases of dehydration or electrolyte imbalances, identifying the underlying cause of delirium through medical history is more urgent.

D. Raise 3 of the 4 side rails of the bed: This action may help prevent falls but does not address the underlying cause of delirium. Moreover, the use of side rails can sometimes increase the risk of injury or entrapment.

A. Echolalia B. Ambivalence C. Expressive affect D. Associative looseness

Correct Answer is A

Explanation

A. Echolalia: Echolalia, the repetition of words or phrases spoken by others, is a common characteristic of autism spectrum disorder. It can be part of the individual’s attempt to communicate or self-stimulate and may be indicative of difficulties in expressive language development.

B. Ambivalence: Ambivalence, the state of having mixed feelings or contradictory ideas about something or someone, is more commonly associated with conditions like schizophrenia, not ASD.

C. Expressive affect: Individuals with ASD often have difficulties with expressive affect, meaning they may show limited emotional expression, which contrasts with the term "expressive affect" suggesting full emotional expression.

D. Associative looseness: Associative looseness, a symptom where a person’s thoughts are disconnected and fragmented, is more characteristic of schizophrenia than ASD.

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The nurse is preparing to discharge a client home from a mental health institution. The nurse should recognize that in order for a mental health client to receive home-bound health care, which of the following criteria must be met?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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