A nurse is caring for a client who attacked one of her friends and is admitted to the psychiatric unit. Which of the following actions should the nurse take first?
Explain the client that the behavior was unacceptable.
Explore the truth of the client's statements.
Set behavioral limits for the client.
Establish a client relationship
The Correct Answer is C
A. Explain to the client that the behavior was unacceptable: While addressing the behavior is important, it is more effective to first establish clear limits and boundaries to prevent further incidents.
B. Explore the truth of the client’s statements: This step involves assessing the client's statements and understanding their perspective, which is important but can be done after setting behavioral limits.
C. Set behavioral limits for the client: Establishing clear behavioral limits is crucial for maintaining safety and order in the psychiatric unit. It helps ensure that the client understands what is expected of them and the consequences of unacceptable behavior. This is particularly important if the client has exhibited aggressive behavior, as it helps prevent further incidents and maintains a safe environment for everyone.
D. Establish a client relationship: Building a therapeutic relationship is essential for effective treatment, but it should be done in the context of a safe environment where clear behavioral expectations have already been established.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I may have a dry mouth while taking this medication.":
Explanation: Correct Answer. Dry mouth is a common side effect of chlorpromazine, which is a typical antipsychotic medication. This statement indicates that the client understands the potential side effects of the medication.
B. "This medication will help me stop smoking.":
Explanation: This statement is incorrect. Chlorpromazine is not used as a medication to aid in smoking cessation. It is primarily used to treat conditions such as schizophrenia and other psychotic disorders.
C. "I should expect flu-like symptoms while taking this medication.":
Explanation: This statement is incorrect. Flu-like symptoms are not a common side effect of chlorpromazine. Side effects more commonly associated with chlorpromazine include drowsiness, dizziness, and movement-related issues.
D. "This medication may cause me to urinate frequently.":
Explanation: This statement is incorrect. While chlorpromazine can cause various side effects, increased frequency of urination is not one of the typical side effects associated with this medication.
Correct Answer is ["2"]
Explanation
The nurse is preparing to administer benztropine 2 mg IM every 12 hours. The concentration of the available benztropine is 1 mg/mL.
To calculate the volume (mL) of the medication needed for the prescribed dose, you can use the formula:
Volume (mL) = Dose (mg) / Concentration (mg/mL)
Plugging in the values:
Volume (mL) = 2 mg / 1 mg/mL = 2 mL
So, the nurse should administer 2 mL of benztropine 1 mg/mL for each dose. Since we're looking for a whole number, we round to the nearest whole number, which is 2 mL.
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