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. "What has helped you through difficult times in the past?": Important but not the priority in a potential crisis.

B. "Has anyone in your family committed suicide?": Relevant but not the first question.

C. "Are you thinking about ending your life?": Directly assesses the client's safety and risk for suicide.

D. "Is there anyone you would like involved in your care?": Supports coping but is not urgent.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Bowel perforation is a serious complication that can occur as a result of necrotizing enterocolitis (NEC), which is a condition often seen in preterm infants. In NEC, the intestines become inflamed and can eventually rupture, leading to bowel perforation. The neonate's symptoms, including abdominal distention, firm abdomen, decreased bowel sounds, and a small amount of blood in the stool, are consistent with NEC. The abdominal x-ray showing marked distention of the intestine further supports this diagnosis.

Necrotizing enterocolitis (NEC) is a common and life-threatening condition in preterm infants (like this neonate born at 34 weeks gestation), particularly those receiving enteral feedings. It can lead to bowel perforation, sepsis, and other serious complications.

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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 caring for a client whose child died from cancer. The client states, "It's hard to go on without him." Which of the following questions should the nurse ask the client first?

Correct Answer is C

Explanation

A nurse is caring for a neonate in the neonatal intensive care unit. Exhibits Complete the following sentence by using the lists of options. The neonate is most at risk for _____ due to ______

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"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.