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 C
Explanation
Explanation
C.I should check my heart rate while taking the medication
Timolol is a medication commonly prescribed for the treatment of primary open-angle glaucoma, which is a chronic eye condition characterized by increased intraocular pressure
hacking the heart rate while taking timolol eye drops is important. Timolol belongs to a class of medications called beta-blockers, which can have systemic effects. These medications can enter the bloodstream and potentially affect heart rate and blood pressure. Monitoring the heart rate can help assess for any potential adverse effects of the medication.
Taking a zinc supplement in (option A) is not correct because it is not typically necessary while taking timolol eye drops. Zinc supplementation is not a direct requirement or related to the use of timolol for glaucoma treatment. The client should follow their healthcare provider's instructions regarding medication use and potential dietary modifications, but zinc supplementation is not specifically associated with timolol.
Timolol eye drops in (option B) is not correct because it does not darken the colour of the eyes. The purpose of timolol eye drops is to reduce intraocular pressure by decreasing the production of fluid in the eye. Eye colour changes are not known effects of timolol eye drops.
Timolol eye drops in (option D) is incorrect because it does not dilate the eyes. In fact, they work by reducing intraocular pressure, not by dilating the eyes. Eye dilation is typically achieved with the use of specific eye drops called mydriatics or with the use of specialized ophthalmic instruments during an eye examination.
Correct Answer is B
Explanation
The plantar Babinski reflex is assessed by stroking the sole of the foot from the heel towards the toes. A normal response is the flexion or curling of the toes. An abnormal response, known as a positive Babinski sign, is the extension and fanning out of the toes, which indicates an upper motor neuron lesion.
"Place your foot in my hand and I will tap the back of your heel": This instruction is more relevant to testing the Achilles tendon reflex, where the nurse taps the back of the heel to elicit a plantarflexion response.
"Sit on the edge of the bed while I tap your knee": This instruction is more relevant to testing the patellar reflex, also known as the knee-jerk reflex. The nurse taps the patellar tendon just below the kneecap to elicit a reflexive contraction of the quadriceps muscle.
"Relax your arm across your chest and I will test your elbow extension": This instruction is more relevant to testing the triceps reflex, where the nurse taps the triceps tendon to elicit a reflexive extension of the elbow.
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