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","C","D","E"]
Explanation
Choice A rationale
Toddlers have high energy needs, so they need a diet that provides enough calories. Parents should be educated on providing a balanced diet that includes a variety of foods to meet their toddler’s nutritional needs.
Choice B rationale
Establishing trust is more relevant to infancy, when babies learn to trust their caregivers to meet their needs. While it’s still important as children grow, it’s not a key point of health promotion education for parents of toddlers.
Choice C rationale
Toddlers often express their independence and frustration through tantrums. Parents should be educated on how to handle tantrums in a calm, consistent manner, and how to teach their child appropriate ways to express their feelings.
Choice D rationale
Cooperative play is a part of social development in toddlers. Parents should be educated on how to encourage this type of play, such as arranging playdates with children of a similar age.
Choice E rationale
Dental care is important for toddlers. Parents should be educated on how to care for their toddler’s teeth and gums, including brushing their teeth twice a day and scheduling regular dental check-ups.
Correct Answer is D
Explanation
Choice A rationale
Phenytoin is an antiepileptic medication used to control seizures. It’s important for the patient to understand that they should not switch brands of this medication without consulting their healthcare provider. Different brands of phenytoin can have different effects, and switching could potentially lead to changes in seizure control.
Choice B rationale
Regular dental appointments are important for patients taking phenytoin. This medication can cause gum overgrowth (gingival hyperplasia), so good oral hygiene and regular dental check- ups are essential.
Choice C rationale
It’s crucial for patients to notify their doctor before taking any other medications. Phenytoin can interact with many other drugs, altering their effectiveness or increasing side effects.
Therefore, the patient’s statement indicates an understanding of the need for caution when considering additional medications.
Choice D rationale
Phenytoin is a long-term medication for controlling seizures. It’s not something that patients can stop taking once they feel better. Abruptly stopping the medication can lead to withdrawal
seizures. Therefore, the patient’s statement, “I’ll be glad when I can stop taking this medicine,” indicates a need for further teaching about the importance of continuing the medication as prescribed.
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