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 D
Explanation
If there is a delay in receiving the new TPN solution from the pharmacy, the nurse should infuse Dextrose 10% in water until the next TPN solution is available. This is because stopping TPN abruptly can cause hypoglycemia. Dextrose 10% in water can provide a source of glucose to prevent hypoglycemia.
Correct Answer is ["1160"]
Explanation
Step 1: Convert All Fluid Intake to Milliliters (mL)
To accurately record the patient's fluid intake, first, convert each fluid measurement to milliliters:
- 1 cup of coffee = 240 mL
- 4 oz of orange juice = 118.3 mL
- 3 oz of water = 88.7 mL
- 1 cup of flavored gelatin = 236.6 mL
- 1 cup of tea = 240 mL
- 5 oz of broth = 147.9 mL
- 3 oz of water (another serving) = 88.7 mL
Step 2: Calculate Total Fluid Intake
Add all the converted fluid amounts together:
- Total fluid intake = 240 mL (coffee) + 118.3 mL (orange juice) + 88.7 mL (water) + 236.6 mL (gelatin) + 240 mL (tea) + 147.9 mL (broth) + 88.7 mL (water) = 1,160.2 mL
Step 3: Round to the Nearest Whole Number
Round the total to the nearest whole number:
- Rounded total = 1,160 mL
The nurse should record 1,160 mL on the patient’s chart.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.