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
Explanation
Choice A rationale
Acute laryngotracheobronchitis, also known as croup, is a common childhood condition that is usually caused by a viral infection. The main symptom is a distinctive barking cough. A cool mist tent can help to soothe the inflamed airways and reduce stridor, which is a high-pitched,
wheezing sound caused by disrupted airflow. Therefore, decreased stridor would indicate that the treatment has been effective.
Choice B rationale
While a decreased temperature might indicate a resolution of any underlying infection, it is not directly related to the effectiveness of a cool mist tent in treating acute laryngotracheobronchitis.
Choice C rationale
A barking cough is a symptom of acute laryngotracheobronchitis and does not indicate treatment effectiveness.
Choice D rationale
Improved hydration is important but is not a direct indicator of the effectiveness of the cool mist tent.
Correct Answer is A
Explanation
The first action the nurse should take when caring for a patient with gastrointestinal bleeding is to assess orthostatic blood pressure. This can help determine the extent of the patient’s blood loss and whether they are experiencing hypovolemia.
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