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 A

Explanation

The correct answer is choicea. Swelling of the face.

Choice A rationale:

Swelling of the face can be a sign of preeclampsia, a serious condition that requires immediate medical attention.Preeclampsia can lead to complications for both the mother and the baby if not managed properly.

Choice B rationale:

Urinary frequency is a common symptom during pregnancy due to hormonal changes and the growing uterus pressing on the bladder.It is generally not a cause for concern unless accompanied by other symptoms like pain or burning during urination.

Choice C rationale:

Faintness upon rising, also known as orthostatic hypotension, is common in pregnancy due to changes in blood circulation.It can often be managed by rising slowly and ensuring adequate hydration.

Choice D rationale:

Bleeding gums are common during pregnancy due to hormonal changes that increase blood flow to the gums, making them more sensitive and prone to bleeding.Good oral hygiene can help manage this symptom.

A. Elevated pain level. B. Increased drowsiness. C. Frequent swallowing. D. Diminished breath sounds.

Correct Answer is C

Explanation

This indicates that the child may be experiencing hemorrhage because they are trying to clear the blood from their throat. Frequent swallowing is one of the initial signs of bleeding immediately after tonsillectomy.
Choice A is wrong because elevated pain level is not a specific sign of hemorrhage. Pain is expected after a tonsillectomy and can be managed with medication and fluids.
Choice B is wrong because increased drowsiness is not a specific sign of hemorrhage. Drowsiness can be caused by anesthesia, medication, or dehydration.

Choice D is wrong because diminished breath sounds are not a specific sign of hemorrhage. Diminished breath sounds can be caused by respiratory infection, asthma, or bronchospasm.
Normal ranges for hemoglobin and hematocrit are 11.5 to 15.5 g/dL and 34 to 45% for children, respectively.
Normal ranges for platelet count are 150,000 to 450,000/mm3 for both children and adults. Normal ranges for plasma clotting variables depend on the specific test and method used.

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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 is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings indicates that the child may be experiencing hemorrhage?

Correct Answer is C

Explanation

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