A nurse working in a mental health facility is caring for a client who is pacing back and forth in the day room while wringing their hands. Which of the following actions should the nurse take?
Ask the client if they would like to watch television.
Use short, simple sentences when speaking with the client.
Allow the client to have 1 hr of time alone in their room.
Move the client to a table where other clients are playing cards.
The Correct Answer is B
By using short, simple sentences, the nurse can effectively communicate with the client who is exhibiting signs of agitation and anxiety. This communication style can help reduce stress and confusion for the client and promote understanding.
Asking the client if they would like to watch television: While providing options for activities can be beneficial, it is important to address the client's current state of agitation and anxiety before suggesting any specific activities.
Allowing the client to have 1 hour of time alone in their room: While some clients may prefer solitude, in this case, the client's pacing and hand-wringing indicate signs of distress and may require therapeutic interventions rather than isolation.
Moving the client to a table where other clients are playing cards: This option may not address the client's current state of anxiety and pacing. Placing the client in a social setting with other clients might increase their distress and agitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Budesonide is a corticosteroid inhaler used for long-term management of asthma. It helps to reduce inflammation and prevent asthma symptoms. Rinsing the mouth and gargling with water after using a corticosteroid inhaler can help reduce the risk of developing oral thrush, a fungal infection.
The other statements are incorrect and indicate a misunderstanding of the teaching: "I will take my inhaler treatment before each meal and at bedtime": Budesonide is not typically used before meals or at bedtime. It is usually taken on a regular schedule, as prescribed by the healthcare provider, to provide long-term control of asthma symptoms.
Using the inhaler before exercising is important because physical activity can trigger asthma symptoms in some individuals. By using the inhaler before exercise, the client can help prevent exercise-induced asthma symptoms. However, this depends on the degree of difficulty of the exercise.
"I should use my inhaler when I have an asthma attack": Budesonide is not a rescue inhaler for immediate relief of asthma symptoms during an asthma attack. It is a controller medication meant to be used regularly to prevent symptoms from occurring.
Correct Answer is C
Explanation
Document the client's behavior leading to the initiation of the restraints: Accurate and comprehensive documentation is essential in the client's medical record. This includes documenting the client's behavior or actions that necessitated the use of restraints. It is important to document the reason, duration, and type of restraint used.
Release the client's restraints every 2 hours or as per institutional policy: It is important to periodically release the restraints to assess the client's circulation, skin integrity, and overall well-being. Restraints should never be kept on continuously without intermittent release. Check the client's status every 15 minutes: The nurse should closely monitor the client's vital signs, level of comfort, and any signs of distress or complications. Frequent assessment ensures early identification and intervention if any issues arise.
Obtain informed consent: While obtaining consent is necessary for many procedures or treatments, including the use of restraints, it is not applicable in situations where there is an imminent risk of harm to the client or others. The use of restraints in mental health units is based on legal and ethical guidelines, prioritizing the client's safety and the safety of others.
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