The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention?
A 16-year-old client diagnosed with major depression who refuses to participate in group.
A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby.
An 18-year-old client with antisocial behavior who is being yelled at by other clients.
A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack.
The Correct Answer is B
Choice A reason: A 16-year-old client diagnosed with major depression who refuses to participate in group does not require the nurse's immediate attention. Depression is a mood disorder that causes persistent feelings of sadness, hopelessness, and loss of interest. Refusing to participate in group may indicate low motivation, social withdrawal, or poor self-esteem, which are common symptoms of depression. The nurse should respect the client's preference and offer alternative activities or individual therapy.
Choice B reason: This client requires immediate intervention because pacing can be a sign of agitation, restlessness, or escalating mania. Clients with bipolar disorder in a manic phase may exhibit increased energy, impulsivity, irritability, and even aggression. If not addressed promptly, this behavior could escalate to disruptive outbursts, impulsive actions, or even violence toward themselves or others. The nurse should intervene by using calm communication, redirection, and possibly medication if prescribed to help de-escalate the situation and ensure safety.
Choice C reason: This scenario involves peer conflict, which is important to address, but it does not necessarily indicate an immediate risk of harm. Clients with antisocial behavior often engage in conflict due to manipulative or confrontational tendencies, but being yelled at does not mean they are in immediate danger. The nurse should monitor the situation and intervene to prevent escalation, but other safety concerns take priority.
Choice D reason: A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack does not require the nurse's immediate attention. Anorexia nervosa is an eating disorder that causes extreme restriction of food intake and fear of weight gain. Refusing to eat the evening snack may indicate distorted body image, dietary rules, or anxiety, which are common factors of anorexia nervosa. The nurse should encourage the client to eat and provide support and education.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice C is correct because serum potassium, calcium, and phosphorus are electrolytes that can be affected by ESRD. ESRD is a condition in which the kidneys lose their ability to filter waste products and excess fluids from the blood. This can cause electrolyte imbalances that can lead to serious complications, such as cardiac arrhythmias, bone disorders, or metabolic acidosis. The nurse should closely monitor these electrolytes and report any abnormal values.
Choice A is incorrect because blood pressure, heart rate, and temperature are vital signs that are not specific to ESRD. Vital signs can be influenced by many factors and may not reflect the severity of kidney damage. The nurse should monitor vital signs regularly, but not as closely as electrolytes.
Choice B is incorrect because leukocytes, neutrophils, and thyroxine are not laboratory results that are directly related to ESRD. Leukocytes and neutrophils are types of white blood cells that are involved in immune response and inflammation. Thyroxine is a hormone that regulates metabolism and growth. These laboratory results may be altered by other conditions or medications, but not by ESRD.
Choice D is incorrect because erythrocytes, hemoglobin, and hematocrit are laboratory results that measure the red blood cell count and oxygen-carrying capacity of the blood. These laboratory results may be decreased in ESRD due to anemia, which is a common complication of chronic kidney disease. However, anemia is not as life-threatening as electrolyte imbalances and can be treated with erythropoietin injections or iron supplements.
Correct Answer is A
Explanation
Choice B reason: Blood pressure of 122/74 mm Hg is within the normal range for a postpartum client and does not indicate an infection. However, the nurse should monitor for signs of preeclampsia or eclampsia, such as hypertension, proteinuria, headache, blurred vision, and seizures.
Choice C reason: Oral temperature of 100.2°F (37.9°C. is slightly elevated, but not necessarily indicative of an infection. A mild fever may occur within the first 24 hours after delivery due to dehydration or hormonal changes. However, if the fever persists or increases, the nurse should suspect an infection and notify the healthcare provider.
Choice D reason: White blood cell count of 19,000/mm^3 (19 x 10^9/L) is higher than the normal range, but not necessarily indicative of an infection. A leukocytosis or increased WBC count may occur as a normal response to stress or trauma during delivery. However, if the WBC count remains elevated or increases further, the nurse should suspect an infection and notify the healthcare provider.
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