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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Nausea and vomiting are common symptoms associated with migraines. Asking about these symptoms can help in assessing the severity of the migraine and planning appropriate interventions.
Choice B rationale
Sensitivity to light, also known as photophobia, is a common symptom of migraines. However, the presence of this symptom alone may not provide a comprehensive understanding of the patient’s condition.
Choice C rationale
While confusion or clouded thinking can occur with migraines, they are not as common as other symptoms such as nausea, vomiting, and sensitivity to light.
Choice D rationale
Feeling weak before the headache starts or currently feeling weak can be associated with migraines, but they are not the most common symptoms.
Correct Answer is D
Explanation
Choice A rationale
Vitamin K is not the antidote for heparin. It is used to reverse the effects of warfarin, which is a vitamin K antagonist.
Choice B rationale
Iron is not related to the reversal of heparin. It is a mineral that is crucial for many bodily functions, including the transport of oxygen in the blood.
Choice C rationale
Glucagon is a hormone that raises the level of glucose in the blood. It is not used as an antidote for heparin.
Choice D rationale
Protamine is the correct choice. Protamine sulfate is a drug that reverses the anticoagulant effects of heparin by binding to it and forming a stable complex, thereby neutralizing its anticoagulant activity.
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