A nurse is admitting a patient exhibiting manic behavior.
The patient reports recent personal stressors, including the loss of her mother and a divorce. What should be the nurse’s priority action?
Encourage self-care.
Assist the patient in identifying coping behaviors.
Prevent self-directed violence.
Identify support systems.
The Correct Answer is C
Choice A rationale
Encouraging self-care is important, but it may not be the immediate priority if the patient is exhibiting manic behavior and has recently experienced significant personal stressors.
Choice B rationale
Assisting the patient in identifying coping behaviors is a key part of treatment, but it may not be the immediate priority if the patient is at risk of self-harm.
Choice C rationale
Preventing self-directed violence is the priority action. Patients exhibiting manic behavior may have impaired judgment and impulse control, putting them at risk of self-harm.
Choice D rationale
Identifying support systems is important, but it may not be the immediate priority if the patient is at risk of self-harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale
Toddlers have high energy needs, so they need a diet that provides enough calories. Parents should be educated on providing a balanced diet that includes a variety of foods to meet their toddler’s nutritional needs.
Choice B rationale
Establishing trust is more relevant to infancy, when babies learn to trust their caregivers to meet their needs. While it’s still important as children grow, it’s not a key point of health promotion education for parents of toddlers.
Choice C rationale
Toddlers often express their independence and frustration through tantrums. Parents should be educated on how to handle tantrums in a calm, consistent manner, and how to teach their child appropriate ways to express their feelings.
Choice D rationale
Cooperative play is a part of social development in toddlers. Parents should be educated on how to encourage this type of play, such as arranging playdates with children of a similar age.
Choice E rationale
Dental care is important for toddlers. Parents should be educated on how to care for their toddler’s teeth and gums, including brushing their teeth twice a day and scheduling regular dental check-ups.
Correct Answer is B
Explanation
Choice A rationale
Lower quadrant pain is a common symptom of many conditions, including ectopic pregnancy. However, it does not specifically indicate the presence of blood in the peritoneum.
Choice B rationale
Cullen’s sign, which is the appearance of bruising in the skin around the umbilicus, is a sign of blood in the peritoneum. It can occur in conditions such as a ruptured ectopic pregnancy.
Choice C rationale
Goodell’s sign is a softening of the cervix that typically occurs early in pregnancy. It does not indicate the presence of blood in the peritoneum.
Choice D rationale
Chadwick’s sign is a bluish discoloration of the cervix, vagina, and labia that occurs in early pregnancy. It does not indicate the presence of blood in the peritoneum.
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