Which should the mental health nurse identify as the priority for a newly admitted client who was involuntarily committed after reports by a co- worker of aggressive behavior?
Client and staff safety
Medication compliance
Client education
Group participation
The Correct Answer is A
a. Client and staff safety: This is correct because ensuring the safety of both the client and staff is the top priority, especially in cases of reported aggression.
b. Medication compliance: While medication compliance is important, it is secondary to ensuring immediate safety in this scenario.
c. Client education: Client education is valuable but may not be the immediate priority when safety concerns are present.
d. Group participation: While group participation may be beneficial for the client's treatment, it is not the priority when safety issues are at stake.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. "Focus on the feelings generated by the hallucinations and present reality." This approach validates the child's experience and feelings while gently orienting them to reality, which is a therapeutic communication technique.
b. "Ignore what they are saying, while attempting to discover the underlying cause." Ignoring the child’s statements can make them feel dismissed and could increase their distress. It is important to address their experience directly and compassionately.
c. "Present objective evidence that the voices are not real." Presenting objective evidence may not be effective as the child’s belief in the voices can be very strong, and this approach may lead to further agitation.
d. "Tell them to stop discussing the voices." This approach is dismissive and does not help the child manage their symptoms or feel understood. It is important to engage with the child’s experience constructively.
Correct Answer is B
Explanation
a. Listen to the breath sounds in all lung fields: Assessing breath sounds is a more complex skill requiring a registered nurse's (RN) assessment.
b. Document the amount of output on the I & O sheet: Documenting intake and output (I&O) is a basic nursing task suitable for unlicensed nursing assistants (UNAs) under supervision.
c. Check the abdominal dressing for bleeding: Checking for bleeding requires a nurse's assessment due to the potential for complications.
d. Increase the IV fluid flow rate if the blood pressure is low: Adjusting IV fluids is a critical intervention requiring an RN's assessment and order.
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