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 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.
Correct Answer is D
Explanation
a. Aphasia: Aphasia is a language disorder that affects a person's ability to communicate. It does not involve the creation of false memories or stories.
b. Delirium: Delirium is an acute, often sudden change in mental status that can cause confusion and impaired attention, but it is not characterized by the fabrication of detailed stories.
c. Apraxia: Apraxia is a motor disorder where a person has difficulty with the motor planning to perform tasks or movements. It does not involve creating false stories.
d. Confabulation: Confabulation involves the creation of false memories or stories without the intention to deceive. This is common in Alzheimer's disease as the brain attempts to fill gaps in memory.
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