A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member requests that the nurse apply restraints. Which of the following responses should the nurse make?

"I will call the doctor and get a prescription."

"I will cover the catheter so he cannot see it."

"I will provide more stimulation in his environment."

"Let's wait until tonight to see if he continues this behavior."

Answer and Explanation

The Correct Answer is B

Choice A reason : While consulting with the healthcare provider is important, immediate action is necessary to prevent harm. Waiting for a prescription may delay intervention.

Choice B reason : When a patient frequently attempts to remove their intravenous (IV) catheter, it's essential to address the behavior promptly to prevent potential complications such as catheter dislodgement, infection, or injury. The most appropriate initial response is to cover the catheter to reduce the patient's awareness and access, thereby decreasing the likelihood of tampering.

Choice C reason : Providing more stimulation could be counterproductive if the client is already agitated or confused. The nurse should assess the client's needs and environment to determine the appropriate level of stimulation.

Choice D reason : Waiting without taking action is not advisable as the client may harm themselves by removing the IV catheter. Immediate intervention is required to ensure the client's safety.

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Correct Answer is A

Explanation

Choice A reason : A sore throat is a common side effect of radiation therapy to the neck area, particularly for cancer of the larynx. The radiation can cause inflammation and irritation of the throat and laryngeal tissues, leading to pain and discomfort when swallowing¹⁵. This side effect can be managed with pain relief medications and dietary adjustments to include softer foods and liquids.

Choice B reason : Dry mouth, or xerostomia, occurs when radiation damages the salivary glands, reducing saliva production. This can lead to difficulties in speaking, tasting, chewing, and swallowing, as well as an increased risk of dental problems¹³. Patients undergoing radiation therapy are often advised to stay hydrated and may be prescribed saliva substitutes or stimulants.

Choice C reason : Radiation to the neck might damage the thyroid gland, leading to hypothyroidism. Symptoms of thyroid problems due to radiation can include fatigue, weight gain, feeling cold, and having dry skin or hair³. Regular monitoring of thyroid function is recommended for patients who have received radiation therapy in the neck area.

Choice D reason : Lymphedema is swelling that can occur when radiation therapy affects the lymph nodes and vessels, impeding the flow of lymph fluid. In the context of neck radiation, this can lead to swelling in the neck and face³. Management includes physical therapy, compression garments, and careful skin care to prevent infection.

A. Answering questions with nonsensical phrases. B. Seeing, hearing, or feeling something that is not really there. C. The feeling that external events such as the weather forecast or news story have special meaning for the patient. D. Trouble staying on a schedule or finishing what the patient starts. E. Inability to socially connect with others.

Correct Answer is ["A","B","C"]

Explanation

Choice A reason : Answering questions with nonsensical phrases is a positive symptom of schizophrenia. It reflects disorganized thinking and speech, which can manifest as incoherence or irrelevance in the patient's verbal communication². This symptom can significantly impair the patient's ability to engage in meaningful conversation and is often one of the more noticeable signs of schizophrenia during an assessment³.

Choice B reason : Seeing, hearing, or feeling something that is not really there, also known as hallucinations, are hallmark positive symptoms of schizophrenia. These sensory experiences occur without an external stimulus and can involve any of the senses, although auditory hallucinations are the most common in schizophrenia². Hallucinations can be extremely distressing for patients and can lead to difficulties in distinguishing reality from delusion³.

Choice C reason : The belief that personal significance is attached to trivial or unrelated external events, known as delusions of reference, is another positive symptom of schizophrenia. Patients may believe that messages are being sent to them through the television, radio, or other public means². This can lead to a profound sense of misunderstanding and isolation as the patient navigates a world they perceive as filled with hidden messages meant specifically for them³.

Choice D reason : While trouble staying on a schedule or finishing tasks can be associated with schizophrenia, it is not considered a positive symptom. These issues are more reflective of the negative symptoms of schizophrenia, which include avolition or the lack of motivation to initiate and complete goal-directed activities⁴.

Choice E reason : An inability to socially connect with others is also not a positive symptom but rather a negative symptom of schizophrenia. Negative symptoms represent a loss or a decrease in the ability to initiate plans, speak, express emotion, or find pleasure in everyday life⁴. Social withdrawal and impaired social interaction are common negative symptoms that can be mistaken for introversion or depression³.

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A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member requests that the nurse apply restraints. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client scheduled to receive external radiation to the neck for cancer of the larynx. During a pre-treatment exam, the nurse explains to the client that the most likely side effect would be :

Correct Answer is A

Explanation

A patient diagnosed with schizophrenia may demonstrate these positive symptoms (select all that apply) :

Correct Answer is ["A","B","C"]

Explanation

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