A nurse is caring for a client on a psychiatric unit.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Requesting to sit in a chair is a normal activity and doesn't indicate a concern.
B. Consuming food from the meal tray is a normal activity and does not require reporting.
C. Requesting assistance to use the bedside commode is a normal activity and does not require reporting unless there is a change in condition.
D. Failing to receive prescribed compression stockings is an important issue because it can increase the risk of deep vein thrombosis (DVT), and it needs to be reported.
Correct Answer is D
Explanation
A. A reddened area without induration is not a positive result.
B. A reddened area without induration is not considered positive.
C. An induration of 5 mm is positive only for high-risk groups (e.g., immunocompromised clients).
D. An induration measuring 10 mm is considered positive in most adults, indicating TB exposure.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.