A nurse on a mental health unit is caring for a newly admitted client.

Exhibits

The nurse is continuing to care for the client. Which of the following actions should the nurse take?(Select All that Apply.)

Gently place a hand on the client's arm during conversation.

Employ active listening skills when communicating with the client.

Administer an anxiolytic medication to the client.

Explain the expected behavioral limits to the client.

Assist the client to identify the source of anger.

Answer and Explanation

Correct Answer : B,C,D,E

A. Gently place a hand on the client's arm during conversation
Avoid touching an anxious or potentially aggressive client-may escalate agitation.

B. Employ active listening skills
Validates feelings and promotes therapeutic communication.

C. Administer an anxiolytic medication
Client is showing signs of withdrawal and agitation-medication may be indicated.

D. Explain behavioral limits
Setting limits provides structure and promotes safety.

E. Assist in identifying source of anger
Supports emotional processing and de-escalation.

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Correct Answer is D

Explanation

A. Coping ability
This is important but not a priority immediately post-op.

B. Surgical dressing
Should be assessed, but airway and tube patency are more urgent.

C. Bowel sounds
Not a priority immediately post-op; expected to be decreased due to anesthesia.

D. Patency of NG tube
Ensures gastric decompression, prevents aspiration, and supports post-op recovery.

A. Preventing musculoskeletal disability B. Stabilizing cardiac arrhythmias C. Decreasing intracranial pressure D. Airway protection

Correct Answer is D

Explanation

A. Preventing musculoskeletal disability
Important, but not priority in life-threatening trauma.

B. Stabilizing cardiac arrhythmias
Secondary-ABCs take precedence.

C. Decreasing intracranial pressure
Important in head injury but only after airway is secure.

D. Airway protection
Airway is the priority in trauma (per ABCs: Airway, Breathing, Circulation).

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A nurse on a mental health unit is caring for a newly admitted client. Exhibits The nurse is continuing to care for the client. Which of the following actions should the nurse take?(Select All that Apply.)

Nursing Test Bank

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A nurse on a mental health unit is caring for a newly admitted client.

Exhibits

The nurse is continuing to care for the client. Which of the following actions should the nurse take?(Select All that Apply.)