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 D
Explanation
Choice A rationale
A biopsy is not typically prescribed for plantar warts unless there is suspicion of a more serious condition, such as cancer.
Choice B rationale
Soaking feet in an antiseptic solution daily is not a standard treatment for plantar warts. Standard treatments include salicylic acid, cryotherapy (freezing), and other methods.
Choice C rationale
Plantar warts are not directly related to excessive foot perspiration. They are caused by the human papillomavirus (HPV) entering a cut or break in the skin.
Choice D rationale
Plantar warts may cause discomfort during walking due to their location on the soles of the feet.
Correct Answer is D
Explanation
Choice A rationale
Lubricating the suction catheter tip with sterile saline is not recommended because it can introduce bacteria into the tracheostomy tube and cause infection.
Choice B rationale
Hyperventilating the patient on 100% oxygen prior to suctioning is not necessary and can cause complications such as oxygen toxicity.
Choice C rationale
Performing chest physiotherapy prior to suctioning is not typically done during tracheostomy care. Chest physiotherapy is a separate procedure that involves physical techniques to remove mucus from the respiratory tract.
Choice D rationale
Suctioning two to three times with a 60-second pause between passes is the correct action. This helps to remove secretions effectively without causing hypoxia.
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