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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is because anticipatory guidance is a type of health teaching that involves sharing information and experiences through educational activities designed to improve health knowledge, attitudes, behaviors, and skills. Anticipatory guidance helps parents to prevent or reduce health problems in their children by providing them with information on topics such as nutrition, immunization, injury prevention, and developmenta milestones. Providing anticipatory guidance classes through public schools is an example of a population-based public health intervention that aims to improve the health of a large group of people who share common characteristics or risks.
Choice A is wrong because tertiary health interventions are not the best way to improve health for the local population. Tertiary health interventions are those that focus on treating and rehabilitating people who have already developed a disease or disability. They are more costly and less effective than primary or secondary health interventions, which aim to prevent or detect diseases early.
Encouraging rural residents to focus health spending on tertiary health interventions would not address the underlying causes of poor health in the community.
Choice B is wrong because having a nurse from outside the community provide health lectures at the county hospital is not a culturally appropriate or accessible way to deliver health education. A nurse from outside the community may not understand the needs, values, beliefs, and practices of the rural residents, and may not be able to establish trust and rapport with them. Moreover, the county hospital may not be a convenient or comfortable location for many rural residents to attend health lectures, especially if they have transportation, financial, or time barriers.
A better approach would be to involve local community members and leaders in planning and delivering health education programs that are tailored to the rural context and culture.
Choice D is wrong because launching a media campaign to increase awareness about industrial pollution is not a sufficient action to improve health for the local population. While increasing awareness is an important first step, it does not necessarily lead to behavior change or environmental improvement.
A media campaign alone would not address the sources and effects of industrial pollution, nor would it provide solutions or resources for the rural residents to protect themselves from exposure.
A more comprehensive action would be to collaborate with other stakeholders, such as environmental agencies, industry representatives, and community groups, to develop and implement strategies for reducing and monitoring industrial pollution and its impact on the environment.
Correct Answer is B
Explanation
Dabigatran is a blood thinner that is used to prevent strokes or blood clots in people with atrial fibrillation, a type of irregular heartbeat. Dabigatran is sensitive to moisture and can lose its potency if exposed to humidity or heat. Therefore, it is important to store it in the original bottle or blister package that has a desiccant (drying agent) in the cap or cover. The client should also close the cap tightly after each use and keep the bottle away from excessive moisture, heat, and cold.
Choice A is wrong because storing the medication in the refrigerator can expose it to moisture and cause it to break down.
Choice C is wrong because crushing the medication and mixing it with applesauce can alter its absorption and effectiveness.
Choice D is wrong because the medication can be used up to 60 days after opening the bottle as long as it is stored properly. The normal dose of dabigatran for stroke prevention in atrial fibrillation is 150 mg twice a day unless the client has kidney problems or other factors that require a lower dose.
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