The plan of care for a patient is not completed within 24 hours of the patient’s admission due to the unit being short-staffed. Which action should the nurse prioritize?
Administer an as-needed dose of an antipsychotic drug
Complete the plan of care as soon as possible
Transfer the patient to another unit
Document the staffing issue in the patient’s chart
The Correct Answer is B
Choice A reason: Administering an antipsychotic without a completed care plan risks inappropriate treatment, as the plan outlines specific needs and interventions. This could lead to adverse effects or mismanagement of the patient’s condition, violating evidence-based practice in psychiatric care, making this choice incorrect.
Choice B reason: Completing the care plan promptly ensures individualized, evidence-based interventions, critical for effective psychiatric treatment. It addresses the patient’s specific needs, guides therapy, and ensures safety, aligning with nursing standards and patient-centered care principles, making this the correct choice for prioritization.
Choice C reason: Transferring the patient to another unit does not address the immediate need for a care plan and may disrupt continuity of care. Staffing issues should be managed locally, and transfer is not a primary solution for incomplete planning, making this choice incorrect.
Choice D reason: Documenting staffing issues, while important for administrative purposes, does not directly address the patient’s immediate care needs. A completed care plan is critical for guiding treatment and ensuring safety, making this choice a lower priority compared to completing the plan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Clozapine, an antipsychotic, primarily causes agranulocytosis and metabolic issues, not fluid or electrolyte imbalances. Its effects on the central nervous system and bone marrow do not directly disrupt electrolyte homeostasis, making this choice incorrect for this concern.
Choice B reason: Lithium, a mood stabilizer, affects renal function, impairing sodium and water reabsorption, leading to potential hyponatremia or dehydration. This requires close monitoring of electrolytes, as imbalances can cause toxicity, making this the correct choice for heightened alertness.
Choice C reason: Fluoxetine, an SSRI, primarily affects serotonin levels, with minimal impact on fluid or electrolyte balance. Side effects like nausea do not significantly disrupt electrolytes, making this choice incorrect compared to lithium’s known renal effects.
Choice D reason: Venlafaxine, an SNRI, influences serotonin and norepinephrine but does not significantly affect fluid or electrolyte balance. Its side effects, like hypertension, are unrelated to electrolyte homeostasis, making this choice incorrect for this specific concern.
Correct Answer is B
Explanation
Choice A reason: Alienation from family corresponds to Maslow’s love and belonging needs, a third-level priority. While important for mental health, it is less urgent than physiological needs like nutrition and hygiene, which are foundational for survival and stability, making this choice lower priority in care planning.
Choice B reason: Refusing to eat or bathe addresses Maslow’s physiological needs, the highest priority in the hierarchy. Nutrition and hygiene are essential for survival and physical health, critical in mental illness to stabilize the patient’s condition and support further treatment, making this the correct choice.
Choice C reason: Reluctance to participate in group therapy relates to esteem or belonging needs, lower in Maslow’s hierarchy. While social engagement aids mental health, it is not as urgent as physiological needs, which underpin survival and basic functioning, making this choice a lower priority in care planning.
Choice D reason: Anxiety about social situations aligns with safety or belonging needs, secondary to physiological requirements. While anxiety impacts mental health, it is less critical than ensuring basic survival needs like food and hygiene, which take precedence in Maslow’s framework, making this choice incorrect.
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