A client on the mental health unit has been scowling and rapidly pacing up and down the hall for several minutes. Which behaviors are most important for the practical nurse (PN) to monitor?
Decreased activity level and change in affect.
Periodic sighing and shaking the head.
Repeated requests for attention from the nurse.
Argumentativeness and use of profanity.
The Correct Answer is D
The most important behaviors for the practical nurse (PN) to monitor in this situation are argumentativeness and use of profanity. These behaviors may indicate that the client is becoming agitated and may pose a risk to themselves or others. The PN should closely monitor the client's behavior and take appropriate action to ensure the safety of the client and others on the unit. The other behaviors listed may also be important to monitor, but argumentativeness and use of profanity are the most important in this situation
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Explanation: Acute otitis media is a common childhood illness that refers to an infection of the middle ear. It occurs when the Eustachian tube, which connects the middle ear to the back of the throat, becomes blocked and fluid accumulates in the middle ear. This fluid provides a breeding ground for bacteria, leading to infection and inflammation. Symptoms of acute otitis media can include ear pain, fever, irritability, and difficulty hearing. It is important for the PN to provide accurate information to the mother and to explain the treatment plan, which may include antibiotics and pain relief measures, as prescribed by the healthcare provider.
Correct Answer is D
Explanation
The practical nurse (PN) should first massage the fundus and expel retained lochia and clots to help the uterus contract and prevent postpartum hemorrhage.
Taking the vital signs and opening the IV infusion rate of oxytocin (A) may be necessary but not as urgent as massaging the fundus.
Notifying the registered nurse (RN) that the client's bladder is distended (B) is not relevant to addressing the client's boggy and displaced fundus.
Putting the infant to breast to suckle and stimulate oxytocin secretion (C) is a valid intervention, but it is not the first priority when the client's fundus becomes boggy and displaced above the umbilicus.
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