A nurse in a mental health facility is collecting a blood specimen from a client.
The client is hallucinating and states, "That looks like a snake, and I won't let it take all of my blood.”. Which of the following responses should the nurse make?.

"I'm using a syringe to obtain your blood, not a snake.”.

"Your provider requires this blood specimen.”.

"You must be mistaken.

Snakes cannot be in the clinic.”.

Answer and Explanation

The Correct Answer is D

(Null)

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Correct Answer is D

Explanation

Choice A rationale:

Teaching sessions right before bedtime may not be effective as older adults may be tired and less able to concentrate.

Choice B rationale:

Establishing long-term goals can be overwhelming for older adults. Short-term goals are more manageable and achievable.

Choice C rationale:

Long teaching sessions may lead to fatigue and decreased concentration. Short, frequent sessions are more effective.

Choice D rationale:

Using “I” statements rather than “you” statements can help create a more positive and collaborative learning environment.

A. "I check my blood pressure once a week.”. B. "I chew sugar-free gum several times daily.”. C. "I haven't had a drink of alcohol since I started taking these injections.”. D. "I spend several hours a day outside gardening when it's sunny.”. .

Correct Answer is D

Explanation

Choice A rationale:

Checking blood pressure once a week is a good practice, especially for clients on medications that can affect blood pressure.

Choice B rationale:

Chewing sugar-free gum several times daily is not harmful and can help with dry mouth, a common side effect of haloperidol.

Choice C rationale:

Avoiding alcohol while taking haloperidol is recommended as alcohol can increase the side effects of the medication.

Choice D rationale:

Spending several hours a day outside gardening when it’s sunny can lead to a condition called photosensitivity, a side effect of haloperidol. The client should be advised to wear protective clothing and sunscreen when outside.

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A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states, "That looks like a snake, and I won't let it take all of my blood.”. Which of the following responses should the nurse make?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with teaching a group of older adult clients about behavioral expectations. Which of the following actions should the nurse take to help eliminate barriers to learning?.

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who started taking haloperidol decanoate 125 mg IM 1 month ago. Which of the following statements by the client should the nurse address?.

Correct Answer is D

Explanation

A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states, "That looks like a snake, and I won't let it take all of my blood.”. Which of the following responses should the nurse make?.

A nurse is caring for a group of clients in a pediatric clinic. Which of the following clients is at the highest risk for physical abuse? .

A nurse is collecting data from a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (Select all that apply.) .

A nurse is contributing to the plan of care for a client who is to start therapy with fluoxetine. Which of the following is an expected outcome for this client?.

A nurse is caring for multiple clients on a mental health unit. Which of the following clients should the nurse attend to first?.

A nurse is reinforcing teaching with a newly licensed nurse about the Patient Self-Determination Act (PSDA). Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?.

A nurse is contributing to the plan of care for a client who has acute delirium. Which of the following interventions should the nurse include in the plan of care? .

A nurse is caring for a client who becomes extremely agitated and asks if they can go to a separate room to be alone for an hour. The nurse should document which of the following de-escalation techniques in the client's medical record?.

A nurse in a mental health facility is collecting a blood specimen from a client.
The client is hallucinating and states, "That looks like a snake, and I won't let it take all of my blood.”. Which of the following responses should the nurse make?.