A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?

Discuss with the client his inappropriate behavior prior to seclusion.

Offer fluids every 2 hr.

Document the client’s behavior prior to being placed in seclusion.

Assess the client’s behavior once every hour.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C: Document the client’s behavior prior to being placed in seclusion.

Choice A rationale:

Discussing with the client his inappropriate behavior prior to seclusion is important, but it’s not the most appropriate action. The priority is to ensure the safety of the client and others, which can be achieved by documenting the client’s behavior prior to seclusion.

Choice B rationale:

Offering fluids every 2 hours is a good practice to keep the client hydrated, especially if they are agitated or physically active. However, this is not the most appropriate action in this context.

Choice C rationale:

Documenting the client’s behavior prior to being placed in seclusion is the most appropriate action. This documentation is crucial for legal and ethical reasons, and it helps in evaluating the effectiveness of the intervention.

Choice D rationale:

Assessing the client’s behavior once every hour is important to monitor the client’s condition and response to seclusion. However, this is not the most appropriate action in this context.

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Correct Answer is C

Explanation

This is because the Glasgow Coma Scale (GCS) is a tool to assess the level of consciousness and neurological status of a client who has a closed head injury. The GCS score can help guide the priority of interventions and the need for further diagnostic tests.
Choice A is wrong because an MRI of the brain is not the first action to take for a client who has a closed head injury. An MRI may be indicated later to evaluate the extent of brain damage, but it is not an emergency procedure.
Choice B is wrong because mannitol IV bolus is a medication that reduces intracranial pressure (ICP) by drawing fluid out of the brain tissue. However, mannitol should not be administered before confirming the presence and degree of increased ICP, which can be done by measuring the GCS score and other vital signs.
Choice D is wrong because inserting an indwelling urinary catheter for the client is not the first action to take for a client who has a closed head injury. A urinary catheter may be needed to monitor fluid balance and renal function, but it is not an urgent intervention.

A. "You can drink beverages that contain caffeine.". B. "You should eat foods that are low in fat.". C. "Notify your provider if you experience vomiting or diarrhea.". D. "Limit alcohol intake to no more than one drink per day.". E. "You should eat foods high in protein.".

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

Explanation

The nurse should include the following statements in the teaching:

You should eat foods that are low in fat. A low-fat diet can help reduce the amount of digestive enzymes your pancreas releases and prevent further inflammation and pain.
Notify your provider if you experience vomiting or diarrhea. These symptoms can lead to dehydration and malnutrition, which can worsen your condition and require hospitalization.
You should eat foods high in protein. Protein can help your body heal and repair damaged tissues. It can also prevent muscle wasting and weight loss, which are common complications of chronic pancreatitis.

Choice A is wrong because caffeine can stimulate the pancreas and increase pain and inflammation. Choice D is wrong because alcohol can damage the pancreas and trigger more attacks. People with chronic pancreatitis should avoid alcohol completely.

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A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a client who has a closed head injury. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse in an emergency department is caring for a client Exhibits The nurse is providing teaching to the client about self-care. Select the 3 statements the nurse should include in the teaching.

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

Explanation

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