The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first?
A family member of a client with dementia who has been missing for five hours.
A client with schizophrenia who wants to stop taking the medications.
The parent of a child who was involved in a physical fight at school today.
A client diagnosed with depression who is experiencing sexual dysfunction.
The Correct Answer is A
Choice A reason: The immediate safety of the client is at risk. A person with dementia who is missing poses a potential danger to themselves due to confusion and the inability to navigate safely in their environment.
Choice B reason: While medication adherence is important for a client with schizophrenia, it does not present an immediate life-threatening situation. The nurse can return this call after addressing more urgent safety concerns.
Choice C reason: Physical altercations at school are serious, but if the child is safe and not in immediate danger, this call can be returned following more urgent issues.
Choice D reason: Sexual dysfunction can significantly affect quality of life, but it is not an immediate safety concern. This call should be returned after more urgent calls have been addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Decreased bowel sounds may indicate gastrointestinal issues but are not directly related to weight gain associated with fluid accumulation in cirrhosis.
Choice B reason: An increased respiratory rate can be a sign of many conditions, including respiratory distress, but it does not correlate specifically with weight gain due to fluid retention in cirrhosis.
Choice C reason: Increased abdominal girth is a common finding in cirrhosis due to ascites, which is the accumulation of fluid in the peritoneal cavity and can lead to significant weight gain.
Choice D reason: Decreased level of consciousness may be a sign of hepatic encephalopathy in cirrhosis but is not a direct correlation to the weight gain reported by the client.
Correct Answer is ["A","C","D"]
Explanation
The correct answer is: a, c, d.
Choice A: Avoid prolonged standing or sitting
Reason: Prolonged standing or sitting can exacerbate symptoms of chronic venous insufficiency (CVI) by increasing venous pressure and promoting blood pooling in the legs. Movement helps to enhance venous return and reduce swelling.
Choice B: Cross legs at the knee but not at the ankle
Reason: Crossing legs at the knee can impede blood flow and increase venous pressure, which is counterproductive for managing CVI. It is generally advised to avoid crossing legs at the knee to promote better circulation.
Choice C: Continue wearing compression stockings
Reason: Compression stockings are a cornerstone in the management of CVI. They help to improve venous return, reduce swelling, and prevent blood from pooling in the legs. Compression stockings should be worn as prescribed, typically during the day and removed at night.
Choice D: Use a recliner for long periods of sitting
Reason: Using a recliner can help elevate the legs above heart level, which reduces venous pressure and promotes venous return. This position can help alleviate symptoms of CVI.
Choice E: Maintain the bed flat while sleeping
Reason: Maintaining the bed flat while sleeping is not recommended for CVI management. Elevating the legs while sleeping can help reduce venous pressure and prevent blood from pooling in the legs.
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