the community mental health nurse is planning to visit four clients with schizophrenia today which client should the nurse see first
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Nursing Elites

ATI LPN

ATI Learning System PN Medical Surgical Final Quizlet

1. The community mental health nurse is planning to visit four clients with schizophrenia today. Which client should the nurse see first?

Correct answer: A

Rationale: The mother who took her children from school due to delusions of aliens poses a significant risk to her children and herself. This situation requires immediate attention to ensure the safety and well-being of all involved. Choice B is concerning due to the history of substance abuse, but the immediate risk to life and safety as in Choice A takes precedence. Choice C, although important, does not present an immediate danger as the delusional belief of aliens. Choice D, while emotionally distressing, does not pose an immediate threat as the situation described in Choice A.

2. A client with deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to assess the effectiveness of the therapy?

Correct answer: C

Rationale: Activated partial thromboplastin time (aPTT) is the appropriate laboratory test to monitor the effectiveness of heparin therapy. Heparin works by prolonging the clotting time, which is reflected in the aPTT results. Monitoring aPTT helps ensure the patient is within the therapeutic range and not at risk of bleeding or clotting complications. Prothrombin time (PT) (Choice A) primarily measures the extrinsic pathway of coagulation and is used to monitor warfarin therapy, not heparin. Platelet count (Choice B) assesses the number of platelets present in the blood and is not specific to monitoring heparin therapy. International normalized ratio (INR) (Choice D) is used to monitor warfarin therapy, not heparin.

3. A client with a history of diabetes mellitus presents with confusion, sweating, and palpitations. What should the nurse do first?

Correct answer: A

Rationale: The correct first action for a client presenting with confusion, sweating, and palpitations, suggestive of hypoglycemia, is to check the client's blood glucose level. This step helps to confirm if the symptoms are due to low blood sugar levels and guides appropriate interventions. Administering insulin without knowing the current blood glucose level can be dangerous and is not recommended as the initial step. Offering a high-protein snack may be necessary after confirming hypoglycemia, but checking the blood glucose level takes precedence. Measuring blood pressure is not the priority in this situation; addressing hypoglycemia is the immediate concern.

4. A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of exquisite abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response?

Correct answer: B

Rationale: In a client with acute diverticulitis experiencing sudden increase in temperature, exquisite abdominal tenderness, and uncharacteristic abdominal rigidity, these signs suggest a possible perforation. The nurse should promptly contact the primary care provider to report these signs, as perforation requires immediate medical attention to prevent further complications.

5. A client with a diagnosis of schizophrenia is being treated with risperidone (Risperdal). Which finding should the nurse report to the healthcare provider immediately?

Correct answer: C

Rationale: Muscle rigidity is a crucial finding to report immediately as it can indicate neuroleptic malignant syndrome (NMS), a rare but potentially life-threatening reaction to antipsychotic medications. NMS is characterized by muscle rigidity, high fever, autonomic dysfunction, and altered mental status. Prompt recognition and intervention are essential to prevent serious complications or death.

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