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.
Assess the client for suicidal ideation.
Allow the client to watch TV at a high volume.
Place the client in a room near the activity room.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D. Contractions.
Choice A Reason: Hypertension Hypertension in pregnancy is a condition that can occur independently of an amniocentesis and is typically monitored throughout the pregnancy. It is characterized by a sustained high blood pressure of 140/90 mmHg or higher. While hypertension is a concern in pregnancy, it is not a direct complication of amniocentesis. Normal ranges for blood pressure in the third trimester are 101.6 to 143.5 mmHg systolic and 62.4 to 94.7 mmHg diastolic.
Choice B Reason: Vomiting Vomiting is not a typical complication following an amniocentesis. It may be associated with other conditions during pregnancy such as hyperemesis gravidarum or gastrointestinal disturbances but is not directly related to the procedure of amniocentesis.
Choice C Reason: Epigastric Pain Epigastric pain is typically associated with conditions like preeclampsia or other gastrointestinal issues in pregnancy, not with amniocentesis. It is characterized by pain in the upper abdomen and is not a common complication post-amniocentesis.
Choice D Reason: Contractions After an amniocentesis, especially at 33 weeks of gestation, monitoring for contractions is crucial because they can indicate preterm labor, which is a known risk associated with the procedure. The normal range for contractions would be none to infrequent Braxton-Hicks contractions, which are not regular and do not signify labor.
Correct Answer is C
Explanation
C) Eat a light snack before bedtime.
The nurse should include the instruction to eat a light snack before bedtime to promote nighttime sleep in an older adult. A light snack can help prevent hunger pangs during the night, making it easier to fall asleep and stay asleep.
The other options are not recommended for promoting nighttime sleep:
A) Performing exercises prior to bedtime can increase alertness and make it more difficult to fall asleep.
B) Taking a 1-hour nap during the day can disrupt the sleep-wake cycle and make it more challenging to sleep at night.
D) Staying in bed for at least 1 hour if unable to fall asleep is not recommended. If the client cannot fall asleep, it's better to get out of bed, engage in a quiet and relaxing activity, and return to bed when feeling sleepy to avoid frustration and anxiety associated with not being able to sleep.
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