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The nurse is caring for assigned clients in the mental health unit. The nurse should initially follow up on the client who
- A. is admitted for psychosis and is pacing in the hallway, mumbling to themselves.
- B. is being treated for obsessive compulsive disorder and has increased the number of times they wash their hands.
- C. has a substance use disorder and refuses to attend group therapy for the second time.
- D. is diagnosed with borderline personality disorder and is insisting on seeing the charge nurse for an allegation of abuse two days ago.
Correct Answer: A
Rationale: Pacing and mumbling in psychosis (A) suggest agitation or worsening symptoms, posing a safety risk requiring immediate follow-up. Increased hand washing (B), therapy refusal (C), and abuse allegations (D) are less urgent, as they are chronic or procedural.
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The nurse is performing an assessment on a client with pneumonia. The nurse should prioritize assessing the client's
- A. temperature.
- B. oral intake.
- C. lung sounds.
- D. white blood cell count.
Correct Answer: C
Rationale: Lung sounds (C) are the priority in pneumonia to assess for consolidation or respiratory compromise, guiding immediate interventions. Temperature (A), intake (B), and WBC count (D) are important but secondary, as they inform longer-term management.
The nurse is triaging phone calls at the mental health clinic. Which client situation requires immediate follow-up? A client prescribed
- A. olanzapine reporting muscle stiffness and feeling hot.
- B. haloperidol reporting blurred vision and constipation.
- C. clozapine reporting occasional twitches of the mouth.
- D. aripiprazole reporting feeling very restless.
Correct Answer: A
Rationale: Muscle stiffness and feeling hot with olanzapine (A) suggest neuroleptic malignant syndrome, a life-threatening emergency requiring immediate follow-up. Blurred vision/constipation (B), mouth twitches (C), and restlessness (D) are less urgent side effects.
While caring for a client who requires a mechanical ventilator for breathing, the high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform?
- A. Disconnect the client from the ventilator and use a manual resuscitation bag.
- B. Perform a quick assessment of the client's condition.
- C. Call the respiratory therapist for help.
- D. Press the alarm reset button on the ventilator.
Correct Answer: B
Rationale: A high-pressure alarm suggests obstruction or resistance, so assessing the client’s condition (B) first identifies the cause (e.g., tube kinking, secretions). Disconnecting (A), calling for help (C), or resetting (D) without assessment risks harm or delays resolution.
A patient in the prenatal clinic has stated her intention to choose formula feeding for her infant. Identify which action by the nurse is most appropriate in being a patient advocate.
- A. Remind the patient of why breast feeding is the best method of infant feeding.
- B. Request a referral to the lactation consultant.
- C. Determine the patient's knowledge base related to infant feeding options.
- D. Accept the patient's decision without further discussion.
Correct Answer: C
Rationale: Determining the patient’s knowledge base (C) respects her autonomy while ensuring informed decision-making, aligning with patient advocacy. Reminding about breastfeeding (A) or referring to a consultant (B) may pressure the patient, and accepting without discussion (D) neglects education.
The nurse is caring for a client who expresses feeling self-conscious about their hair and states they would like to wash it before undergoing diagnostic tests and procedures. How should the nurse prioritize the client's care?
- A. Offer the client a cap or scarf to cover their hair and suggest washing it after the diagnostic tests are complete.
- B. The nurse should schedule the testing and meal planning first and complete hygiene as time permits.
- C. Perform the dressing changes first, schedule testing, counsel, and complete hygiene last.
- D. Arrange to wash the client's hair first, perform hygiene, and then complete the diagnostic testing and counseling.
Correct Answer: A
Rationale: Offering a cap/scarf and suggesting washing later (A) addresses the client’s emotional needs while prioritizing timely diagnostics, ensuring medical care is not delayed. Scheduling tests first (B), prioritizing dressings (C), or washing hair first (D) either delays care or ignores efficiency.