A nurse in a mental health facility is caring for a client.
For each potential nursing action, click to specify if the potential action is anticipated, nonessential, or contraindicated for the client.
Offer sympathy and attention to maladaptive behavior.
Maintain same staff members caring for the client.
Encourage the client to talk about feelings prior to maladaptive behavior.
Initiate suicide precautions.
Explore feelings of abandonment with the client.
Instruct the client to avoid foods with tyramine.
Apply wrist restraints.
Offer the client opportunities for physical exercise.
The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"C"},"H":{"answers":"A"}}
Anticipated Actions:
Maintain same staff members: Provides consistency and builds trust—essential in managing clients with emotional instability.
Encourage talking about feelings prior to self-harm: Helps identify emotional triggers and promotes healthy coping strategies.
Initiate suicide precautions: Critical given self-harm, feelings of hopelessness, and verbalizations of loneliness.
Explore feelings of abandonment: Therapeutic to address the underlying emotional distress linked to relationship loss.
Offer opportunities for physical exercise: Can reduce tension and improve mood in a structured, healthy way.
Contraindicated Actions:
Offer sympathy and attention to maladaptive behavior: Reinforces self-harm as a means to gain attention, which can perpetuate the behavior.
Apply wrist restraints: Physical restraints are only appropriate when a client poses an immediate risk to self or others and all less restrictive options have failed. In this scenario, suicide precautions and monitoring are more appropriate first-line interventions.
Non-essential Action:
Instruct the client to avoid foods with tyramine: Relevant only if the client is taking MAOIs (e.g., phenelzine), which isn’t indicated in the scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Airway patency is the priority to monitor following a thyroidectomy. The surgical site is close to the neck and airway, and there is a risk of postoperative complications such as swelling, bleeding, or the formation of a hematoma that could compromise the airway. Immediate attention to airway management is crucial to ensure that the client can breathe freely and maintain adequate oxygenation.
B. Urination is important to monitor postoperatively, but it is not the immediate priority following a thyroidectomy. Urination can be affected by fluid balance or medications, but ensuring airway patency takes precedence over urinary output.
C. Temperature is important to monitor as it can indicate infection or other complications, but airway concerns are more urgent immediately following thyroid surgery. Fever can be managed once the airway is secure.
D. Pain control is necessary for comfort and recovery, but pain is not the most urgent concern in the immediate postoperative period compared to airway patency. Pain management can be addressed after ensuring the client’s airway is clear and safe.
Correct Answer is A
Explanation
A. “I will need to wipe my perineal area from back to front after urination” indicates a need for further teaching. Wiping from back to front increases the risk of introducing bacteria from the anal area into the urethra, which can lead to a urinary tract infection. The correct method is to wipe from front to back.
B. “I will need to drink apple cider vinegar each day” is a common home remedy belief. While scientific evidence is limited, apple cider vinegar is thought by some to help maintain urinary tract health due to its potential antibacterial properties. This statement does not necessarily indicate a misunderstanding.
C. “I need to drink 8 cups of liquid each day” is correct. Adequate fluid intake helps flush bacteria from the urinary tract and reduces the risk of infection.
D. “I will need to empty my bladder regularly and completely” is correct. Incomplete bladder emptying or infrequent urination can promote bacterial growth, so regular and full voiding helps prevent UTIs.
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