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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A rationale
A chest x-ray is a critical diagnostic tool for a patient presenting with flu-like symptoms, fever, chest congestion, and increased breathing difficulties. It can help identify conditions such as pneumonia or other lung diseases, which could be causing the patient’s symptoms.
Choice B rationale
While hydration is important, running a 0.9% sodium chloride IV infusion at 150 mL/hour is not the most immediate need for this patient. The patient’s symptoms are primarily respiratory, and there is no indication of dehydration.
Choice C rationale
A sputum culture could be useful for diagnosing bacterial infections of the respiratory tract. However, it is not the most immediate need for this patient, as the results of a culture test can take time to come back.
Choice D rationale
This is the correct answer. Given the patient’s increased breathing difficulties, starting oxygen therapy can help improve the patient’s oxygen levels and ease their breathing.
Choice E rationale
Starting a peripheral IV might be necessary for administering medications or fluids, but it is not the most immediate need in this scenario.
Choice F rationale
While controlling the patient’s fever is important, it is not as immediate a need as performing a chest x-ray and starting oxygen therapy.
Correct Answer is ["100"]
Explanation
Step 1: The child is receiving gentamicin 60 mg every 8 hours IV, which is to be infused over 30 minutes. The medication is delivered by the pharmacy diluted in a 50 ml bag of saline.
Step 2: We need to find the infusion pump’s regulation in mL/hour.
Step 3: Since the medication is to be infused over 30 minutes, we convert this to hours by dividing by 60. So, 30 minutes is 0.5 hours.
Step 4: The rate of infusion is then the total volume (50 mL) divided by the time in hours (0.5 hours).
Step 5: So, the infusion pump’s regulation is (50 mL ÷ 0.5 hours) = 100 mL/hour.
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