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 B

Explanation

Choice A rationale:

Documenting the client’s behavior every hour is not necessary. The nurse should monitor and document the client’s condition, but this does not need to be done every hour.

Choice B rationale:

Providing range-of-motion exercises to all extremities every 2 hours is important when a client is in restraints. This helps to prevent muscle stiffness and maintain circulation.

Choice C rationale:

The provider does not need to renew the prescription every 24 hours. The use of restraints should be reassessed regularly, but a new prescription is not required unless the restraints are removed and then need to be reapplied.

Choice D rationale:

Keeping staff interactions with the client to a minimum is not recommended. The client should be monitored closely and regular interaction can help to calm the client and reduce the need for restraints.

A. "Having a newborn must be stressful. Do you have other children?". B. "Tell me about your baby. Where is she now?". C. "Do you have a friend who could help you?". D. "Have you discussed this with your partner?".

Correct Answer is B

Explanation

Choice A rationale:

While it’s important to understand the client’s situation, the immediate safety of the baby is the priority.

Choice B rationale:

This response is the priority as it assesses the immediate safety of the baby.

Choice C rationale:

While support is important, the immediate safety of the baby is the priority.

Choice D rationale:

While communication with the partner is important, the immediate safety of the baby is the priority.

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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 caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior. Which of the following actions should the nurse take?.

Correct Answer is B

Explanation

A client who delivered a healthy newborn 4 weeks ago calls her provider's office and tells the nurse, "This baby constantly cries. My partner works all the time, and I can't take any more.”. Which of the following responses is the nurse's priority?.

Correct Answer is B

Explanation

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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?.