A nurse is assisting in the care of a client in a mental health facility. During group therapy, the client stands up and starts pacing with their fists clenched. Which of the following actions should the nurse take first?

Administer haloperidol via the intramuscular route.

Collect data regarding the client's feelings.

Obtain assistance to apply wrist restraints.

Move the client into the seclusion room.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Administer haloperidol via the intramuscular route: Medication may be necessary for agitation, but administering it before assessing the client’s emotional state and safety is premature and could escalate distress.

B. Collect data regarding the client’s feelings: Assessing the client’s emotional state and reasons for pacing and clenched fists helps identify triggers, enabling the nurse to choose the least restrictive intervention and promote de-escalation.

C. Obtain assistance to apply wrist restraints: Restraints are a last resort to ensure safety and should only be used after less restrictive interventions have failed and when the client poses an immediate risk to self or others.

D. Move the client into the seclusion room: Seclusion is also a restrictive intervention requiring assessment of necessity. Moving the client without first gathering data and attempting de-escalation may violate client rights and worsen agitation.

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Correct Answer is B

Explanation

Rationale:

A. Arterial blood gases: While ABGs assess respiratory and metabolic balance, they are not routinely monitored for clients on furosemide. This test is more relevant for clients with severe respiratory or acid-base disorders, not as a direct indicator of diuretic therapy effects.

B. Blood urea nitrogen: Furosemide is a loop diuretic that can affect kidney function by reducing circulating blood volume. Monitoring BUN helps assess renal perfusion and detect early signs of dehydration or nephrotoxicity associated with diuretic use.

C. Prothrombin time: PT evaluates coagulation status, typically in clients taking anticoagulants like warfarin. Furosemide does not affect clotting pathways, so PT monitoring is unnecessary in this context unless the client is on anticoagulants for another condition.

D. Thyroid stimulating hormone: TSH measures thyroid function but is not influenced by furosemide. There is no established link between furosemide and thyroid activity that would necessitate routine TSH monitoring for clients taking this medication.

A. Place eye covers on the newborn while under the lights. B. Apply an emollient lotion to skin that is exposed to the lights. C. Remove all blankets, clothing and diapers while the newborn is under lights D. Keep the newborn as close to the light source as possible.

Correct Answer is A

Explanation

Rationale:

A. Place eye covers on the newborn while under the lights: Eye protection is essential during phototherapy to prevent retinal damage from the high-intensity blue light. The covers should be properly fitted and removed only during feedings or when the therapy is paused.

B. Apply an emollient lotion to skin that is exposed to the lights: Emollients are not recommended during phototherapy because they can increase the risk of burns or interfere with light penetration. The newborn’s skin should remain clean and dry to ensure safety and effective treatment.

C. Remove all blankets, clothing and diapers while the newborn is under lights: While minimal clothing is used to expose as much skin as possible, the diaper is typically kept in place to protect the genital area and reduce the risk of contamination. Full removal is not necessary or recommended.

D. Keep the newborn as close to the light source as possible: The distance between the newborn and the phototherapy light should be within manufacturer guidelines. Moving the newborn too close can increase the risk of overheating or skin damage, so positioning must follow safety standards.

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A nurse is assisting in the care of a client in a mental health facility. During group therapy, the client stands up and starts pacing with their fists clenched. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a prescription for furosemide, which of the following laboratory tests should the nurse monitor?

Correct Answer is B

Explanation

A nurse is caring for a newborn who has an order for phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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