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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Gentamicin is an aminoglycoside antibiotic that is known to have potential ototoxicity, which means it can cause damage to the inner ear and result in hearing loss. It is important for the nurse to monitor the client's hearing during gentamicin therapy and report any changes or symptoms of hearing loss promptly. Other adverse effects of gentamicin may include nephrotoxicity (kidney damage), so monitoring renal function is also essential.

Hypotension, constipation, and slurred speech are not typically associated with gentamicin use. However, it is important for the nurse to monitor the client for any adverse effects and report any concerning symptoms to the healthcare provider.

A. Chemotherapy treatments B. Medications for a cardiac anomaly C. Clear rhinorrhea D. Two diarrhea stools in the last day

Correct Answer is A

Explanation

Chemotherapy treatments, which are used to treat cancer, can suppress the immune system and weaken the body's ability to respond to vaccines. As a result, receiving a live attenuated vaccine like the varicella immunization can pose a risk of severe complications for individuals undergoing chemotherapy. Therefore, it is contraindicated to administer the varicella vaccine in this case.

Medications for a cardiac anomaly, clear rhinorrhea, and two diarrhea stools in the last day are not contraindications for receiving a varicella immunization.

While medications for a cardiac anomaly and certain medical conditions may require special consideration or precautions when administering vaccines, they are not absolute contraindications for the varicella vaccine. The decision to administer the vaccine would depend on the individual's specific circumstances and the healthcare provider's assessment. Clear rhinorrhea (runny nose) and two diarrhea stools in the last day are considered minor illnesses and do not contraindicate the varicella vaccine. Generally, mild illnesses without fever or systemic symptoms do not pose a significant risk when receiving vaccines. However, it is always important to assess the overall health status of the individual and consult with a healthcare provider if there are concerns.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

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