A nurse is caring for a patient who attacked a friend and is now admitted to the psychiatric unit. Which of the following actions should the nurse take first?

Establish a patient relationship.

Explore the truth of the patient’s statements.

Set behavioral limits for the patient.

Explain to the patient that the behavior was unacceptable.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Establishing a patient relationship is important, but it’s not the first action the nurse should take. The nurse must first ensure safety for all involved.

Choice B rationale

Exploring the truth of the patient’s statements is a part of the therapeutic process, but it’s not the first step. The immediate concern should be to ensure safety.

Choice C rationale

Setting behavioral limits for the patient is the first action the nurse should take. This is crucial in managing a patient who has shown aggressive behavior. It helps to establish boundaries and expectations, which can prevent further aggressive incidents.

Choice D rationale

While it’s important to explain to the patient that the behavior was unacceptable, this is not the first action. The immediate priority is to ensure safety by setting behavioral limits.

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Correct Answer is A

Explanation

Choice A rationale

Stage I pressure injury is characterized by non-blanchable erythema of intact skin. This means that the skin does not turn white when pressed and is a sign of damage to the underlying

tissues. This stage is often seen in areas of the body that are under constant pressure, such as the heels in a patient who is unable to move.

Choice B rationale

Stage II pressure injury involves partial-thickness loss of skin with exposed dermis. This stage is more severe than stage I and would present with an open wound, which is not described in the question.

Choice C rationale

Stage III pressure injury involves full-thickness loss of skin, in which fatty tissue is visible in the wound. This stage is more severe than both stages I and II and would present with a deeper wound, which is not described in the question.

Choice D rationale

Stage IV pressure injury involves full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone. This is the most severe stage of pressure injury and would present with a very deep wound exposing underlying structures, which is not described in the question.

A. The medication will decrease coughing episodes. B. The medication will prevent wheezing. C. The medication will open the airways. D. The medication will stimulate the flow of mucus. E. The medication will reduce inflammation.

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

Explanation

Choice A rationale

Albuterol does not directly decrease coughing episodes. Coughing can be a symptom of an underlying condition like asthma, which albuterol can help manage by relaxing the muscles around the airways. However, the medication itself does not have a direct effect on coughing.

Choice B rationale

Albuterol helps prevent wheezing by relaxing the muscles around the airways, allowing them to open up and making it easier to breathe. Wheezing is a common symptom of conditions like asthma, which albuterol is often used to treat.

Choice C rationale

Albuterol works by opening the airways of the lungs, making it easier to breathe. It does this by relaxing the muscles around the airways, allowing more air to flow into the lungs.

Choice D rationale

Albuterol does not stimulate the flow of mucus. While it can help manage symptoms of conditions like asthma, it does not have a direct effect on mucus production.

Choice E rationale

Albuterol does not directly reduce inflammation. It works by relaxing the muscles around the airways, which can help alleviate symptoms of conditions characterized by inflammation, such as asthma. However, the medication itself does not have anti-inflammatory properties.

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A nurse is caring for a patient who attacked a friend and is now admitted to the psychiatric unit. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is attending to a patient who is unable to move.Which stage of pressure injuries is most likely indicated by the presence of non-blanchable erythema on the patient’s heels?

Correct Answer is A

Explanation

A nurse is caring for a patient who wants to know how albuterol aids his breathing. What should the nurse’s response be? (Select all that apply)

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

Explanation

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