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 B

Explanation

A. Offer small amounts of clear liquids 6 hr following surgery: Typically, clear liquids can be introduced earlier if the child is awake and has no nausea.

B. Administer analgesics on a scheduled basis for the first 24 hr: Scheduled analgesia provides consistent pain relief, improving comfort and facilitating early mobilization, which is essential for preventing complications such as ileus or pneumonia.

C. Give cromolyn nebulized solution every 8 hr: Cromolyn is used for asthma, not postoperative care.

D. Apply a warm compress to the operative site once daily: Heat application to the surgical site is contraindicated as it may promote infection.

A. Select a site on the client's dominant arm. B. Elevate the client's arm prior to insertion. C. Choose a vein that is palpable and straight. D. Apply a tourniquet below the venipuncture site.

Correct Answer is C

Explanation

A. The nondominant arm is preferred to reduce discomfort and interference with the client's activities.

B. Elevating the arm reduces venous filling and is not recommended before IV insertion.

C. Selecting a vein that is palpable and straight minimizes complications and improves the success of the IV insertion.

D. The tourniquet should be applied above the venipuncture site to engorge the veins and make them more accessible.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care?

Correct Answer is B

Explanation

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Correct Answer is C

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.