Difficulty: Medium
Average Score: 89%
Simulated
A nurse is caring for a client who has a serious mental illness. The client states, 'Kiss me baby! You know you want to!' Which of the following should the nurse identify as the priority to address?
Correct answer
D
Rationale
The correct answer is D because the client's statement displays inappropriate behavior that may be indicative of boundary issues or sexual harassment. The nurse should address this behavior immediately to ensure the client's safety and well-being, as well as maintain professional boundaries.
Choice A is not the priority as the client's blood pressure is slightly elevated but not an immediate concern. Choice B is also not the priority as the client's heart rate is within normal limits. Choice C may be a concern for heat exhaustion but does not take precedence over addressing the client's inappropriate behavior.
Choice A is not the priority as the client's blood pressure is slightly elevated but not an immediate concern. Choice B is also not the priority as the client's heart rate is within normal limits. Choice C may be a concern for heat exhaustion but does not take precedence over addressing the client's inappropriate behavior.