A nurse is caring for a client on a psychiatric unit.

Exhibits

For each potential action, click to specify if the action is indicated or contraindicated for the client.

Ask the client about the content of their hallucinations.

Instruct the client on expected hygiene practices.

Allow the client to watch TV at a high volume.

Assess the client for suicidal ideation.

Place the client in a room near the activity

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"}}

Potential action	Indicated	Contraindicated
Ask the client about the content of their hallucinations.	✓
Instruct the client on expected hygiene practices.	✓
Allow the client to watch TV at a high volume.		✓
Assess the client for suicidal ideation.	✓
Place the client in a room near the activity		✓

Rationale

Ask the client about the content of their hallucinations: Indicated
- Understanding the content of hallucinations can help in assessing the severity and nature of the client's condition, and in planning appropriate interventions.
Instruct the client on expected hygiene practices: Indicated
- Encouraging and educating the client about personal hygiene is important for their overall well-being and social interactions.
Allow the client to watch TV at a high volume: Contraindicated
- High volume and excessive stimulation can exacerbate symptoms of schizophrenia, such as hallucinations and agitation.
Assess the client for suicidal ideation: Indicated
- Regular assessment for suicidal thoughts is crucial, even if the client initially denies them, as their mental state can change.
Place the client in a room near the activity: Contraindicated
- A quieter environment is generally more beneficial for clients with schizophrenia to reduce overstimulation and stress.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. White flour tortillas contain gluten and should be avoided.

B. Wheat crackers contain gluten and are inappropriate for celiac disease.

C. Potato pancakes are a gluten-free option and appropriate for a client with celiac disease, as they do not contain wheat, barley, or rye.

D. Barley soup contains gluten and is not safe for clients with celiac disease.

A. Position the client's knees slightly higher than the hips when up in a chair. B. Keep an abduction pillow between the client's legs. C. Raise the head of the client's bed to a high-Fowler's position. D. Elevate the client's affected leg on a pillow when in bed.

Correct Answer is B

Explanation

A. Positioning the knees higher than the hips could increase the risk of hip dislocation.

B. Keeping an abduction pillow between the legs helps maintain the hip in the correct position and prevents dislocation.

C. Raising the head of the bed to a high-Fowler’s position may strain the hip and is not recommended for dislocation prevention.

D. Elevating the affected leg on a pillow may cause internal rotation and increase the risk of dislocation.

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A nurse is caring for a client on a psychiatric unit. Exhibits For each potential action, click to specify if the action is indicated or contraindicated for the client.

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A nurse is caring for a client on a psychiatric unit.

Exhibits

For each potential action, click to specify if the action is indicated or contraindicated for the client.