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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Correct Answer is D

Explanation

A. Physical activity should be scheduled earlier in the day to prevent overstimulation and promote restful sleep.

B. Hardwood floors increase the risk of falls; carpets provide better traction and cushioning.

C. Zippers can be difficult for clients with Alzheimer's; clothing with Velcro or simple fasteners is preferred.

D. Placing locks at the tops of doors reduces the risk of wandering, a common safety concern in clients with Alzheimer's.

A. Increased pain B. Hyperglycemia C. Hypoventilation D. Somnolence

Correct Answer is A

Explanation

A. Increased pain: Naloxone is an opioid antagonist and will reverse the analgesic effects of the opioid, likely leading to increased pain in the client.

B. Hyperglycemia: Incorrect. Naloxone does not typically cause changes in glucose metabolism.

C. Hypoventilation: Incorrect. Naloxone reverses respiratory depression, so hypoventilation is not expected after its administration.

D. Somnolence: Incorrect. Naloxone should reverse somnolence caused by opioids, leading to more alertness.

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Body Systems	Findings
Respiratory	Respiratory rate 26/min
Cardiovascular	Heart rate 112/min Capillary refill 4 seconds
Gastrointestinal	Hyperactive bowel sounds
Integumentary	Diaper area reddened with erythema noted Extremities cool Reports no tears
Neurologic	Lethargic

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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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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.