A client on the mental health unit has been displaying signs of agitation, such as scowling and pacing rapidly up and down the hallway for several minutes.
Which behaviors should the nurse prioritize for monitoring?

Periodic sighing and shaking of the head.

Decreased activity level and change in affect.

Repeated requests for attention from the nurse.

Argumentativeness and use of profanity.

Answer and Explanation

Correct Answer : A,C,D

Choice A rationale
Periodic sighing and shaking of the head can be signs of agitation and distress. These behaviors may indicate that the client is struggling to manage their emotions and may need additional support or intervention.
Choice B rationale
A decreased activity level and change in affect can be signs of many different mental health conditions, but they are not typically associated with agitation. Therefore, while these behaviors should be monitored, they are not the priority in this situation.
Choice C rationale
Repeated requests for attention from the nurse can be a sign of agitation. This behavior may indicate that the client is feeling distressed and is seeking help in managing their emotions.
Choice D rationale
Argumentativeness and use of profanity are clear signs of agitation. These behaviors can escalate quickly and may pose a risk to the safety of the client and others on the unit.
Therefore, these behaviors should be prioritized for monitoring.

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Correct Answer is B

Explanation

Choice A rationale
While regular monitoring of blood sugar levels is important in managing diabetes, checking every four to six hours every day may not be necessary for all patients. The frequency of blood glucose monitoring should be individualized based on the type and severity of the diabetes, the patient’s blood glucose control, and the patient’s specific needs.
Choice B rationale

Keeping diabetic medication on schedule as prescribed is crucial in managing blood glucose levels and preventing complications related to diabetes. This indicates that the patient has understood the importance of medication adherence in diabetes management.
Choice C rationale
While it’s recommended to limit alcohol consumption, restricting alcoholic beverages to no more than 1-2 per week is not a standard guideline for all patients with diabetes. The effects of alcohol on blood glucose levels can vary depending on several factors, including the amount of alcohol consumed, the presence of food, and the individual’s overall diabetes management.
Choice D rationale
Limiting daily fat intake to 15% of total calories is not a standard recommendation for patients with diabetes. The American Diabetes Association recommends individualized medical nutrition therapy to manage diabetes, which may include monitoring carbohydrate intake and considering the quality of fats and proteins in the diet.

A. The patient’s currently prescribed medications. B. The increasing confusion of the patient. C. The patient’s healthcare power of attorney. D. The fall from a ladder as the reason for admission.

Correct Answer is D

Explanation

Choice A rationale
While it’s important to know the patient’s current medications as they can influence the patient’s condition and treatment plan, this information is not the most critical to convey first in this situation.
Choice B rationale
The increasing confusion of the patient is a significant symptom, especially after a fall. It could indicate a possible head injury. However, the cause of the confusion (the fall) should be communicated first.
Choice C rationale
Knowing who holds the patient’s healthcare power of attorney is important, especially if the patient’s condition worsens and decisions need to be made on their behalf. However, this information is not the most critical to convey first.
Choice D rationale
The fall from a ladder as the reason for admission is the most important information to provide first. This gives the healthcare provider immediate context about the potential severity and type of injuries, guiding further assessment and treatment.

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A client on the mental health unit has been displaying signs of agitation, such as scowling and pacing rapidly up and down the hallway for several minutes. Which behaviors should the nurse prioritize for monitoring?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is educating a patient who was admitted with a blood glucose level of 580 mg/dL on how to prevent complications related to diabetes mellitus. Which statement, if made by the patient, would indicate that they have understood the teaching?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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A client on the mental health unit has been displaying signs of agitation, such as scowling and pacing rapidly up and down the hallway for several minutes.
Which behaviors should the nurse prioritize for monitoring?