What is the purpose of a nurse gathering client information?

enables the nurse to assign the appropriate Axis i diagnosis

enables the nurse to prescribe the appropriate medications

enables the nurse to mortify behaviors related to personality disorders

enables the nurse to make sound clinical judgments and plan appropriate care

Answer and Explanation

The Correct Answer is D

A. Enables the nurse to assign the appropriate Axis I diagnosis: Nurses typically do not assign Axis I diagnoses. Diagnosing mental health conditions is typically the responsibility of psychiatrists, psychologists, or other licensed mental health professionals. Nurses, however, play a crucial role in gathering information to contribute to the overall assessment process.

B. Enables the nurse to prescribe the appropriate medications: Nurses do not prescribe medications; that is the responsibility of physicians, nurse practitioners, or other prescribers. However, gathering client information is essential for providing accurate information to the prescriber, assisting in medication management, and monitoring for side effects.

C. Enables the nurse to modify behaviors related to personality disorders: While nurses can assist in the management of behaviors related to mental health conditions, the primary purpose of gathering client information is not to modify behaviors related to personality disorders. It is more about understanding the client's needs and tailoring care accordingly.

D. Enables the nurse to make sound clinical judgments and plan appropriate care: This is the correct answer. Gathering client information is a fundamental step in the nursing assessment process. It provides the necessary data for the nurse to make informed clinical judgments, identify health problems, and plan appropriate care interventions. It allows the nurse to understand the client's unique needs, preferences, and potential risks, leading to individualized and effective care planning.

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Correct Answer is A

Explanation

A. Note escalating behaviors and intervene immediately:

This option prioritizes the client's safety by addressing escalating behaviors promptly. Bizarre behaviors, neologisms, and thought insertion may indicate a severe episode of psychosis, and timely intervention is crucial to prevent harm to the client or others.

B. Interpret attempts at communication:

While understanding and interpreting communication are important, in a situation with escalating behaviors and potential safety concerns, immediate intervention takes precedence. Communication interpretation can follow once the safety of the client has been ensured.

C. Assess for medication noncompliance:

Medication noncompliance can contribute to exacerbation of symptoms, but in an acute situation where safety is a concern, addressing immediate behaviors takes precedence. Medication assessment can be done in the context of a more comprehensive assessment after the immediate safety concerns have been addressed.

D. Assess triggers for bizarre, inappropriate behaviors:

Identifying triggers is important for understanding the underlying causes of the behavior, but in the context of escalating behaviors and potential safety issues, immediate intervention to de-escalate the situation is the priority. Triggers can be explored once the immediate safety concerns are addressed.

A. hypotensive shock B. hypertensive crisis C. cardiac dysrhythmia D. cardiogenic shock

Correct Answer is B

Explanation

A. Hypotensive shock: This is not the correct answer. MAO inhibitors are not associated with causing hypotensive shock. In fact, they can lead to an increase in blood pressure.

B. Hypertensive crisis: This is the correct answer. MAO inhibitors interact with certain foods and drugs, such as those containing tyramine, leading to an increased risk of a hypertensive crisis. Foods rich in tyramine, such as aged cheeses, certain wines, and some processed meats, can cause a sudden and dangerous increase in blood pressure when combined with MAO inhibitors.

C. Cardiac dysrhythmia: While all medications have potential side effects, MAO inhibitors are not typically associated with causing cardiac dysrhythmias.

D. Cardiogenic shock: MAO inhibitors are not known to cause cardiogenic shock. The primary concern with MAO inhibitors is the potential for a hypertensive crisis due to interactions with specific foods and drugs.

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What is the purpose of a nurse gathering client information?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this clients safety?

Correct Answer is A

Explanation

A nurse instructs a patient taking a drug that inhibits monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of:

Correct Answer is B

Explanation

A 16-year-old client diagnosed with schizophrenia experiences command hallucinations to harm others. The clients parents ask a nurse. Where do the voices come from? Which is the appropriate nursing reply?

A nurse cares for four patients who are receiving clozapine, lithium, fluoxetine, and venlafaxine, respectively. For which patient should the nurse be most alert for alterations in cardiac or cerebral electrical conductivity as well as fluid and electrolyte imbalance? The patient receiving:

A client diagnosed with borderline personality disorder brings up a conflict with the staff in a community meeting and develops a following of clients who unreasonably demand modification of unit rules. How can the nursing staff best handle this situation?

A charge nurse is instructing a newly licensed nurse about mental health disorders. Which of the following statements by the nurse indicates an understanding of mental health disorders?

A 19 year old patient has a diagnosis of Borderline personality disorder. The patient approaches the nurse and shows multiple fresh cuts on both arms. Which is the most therapeutic response by the nurse?

During an assessment interview, a client diagnosed with antisocial personality disorder spits, curses, and refuses to answer questions. Which is the most appropriate nursing statement to address this behavior?

A nurse on an in-patient unit received the report at 15:00 hours. Which client should the nurse see first?

A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome during the first week of hospitalization?