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. Epistaxis
Heparin is an anticoagulant medication used to prevent blood clot formation. One of the potential adverse effects of heparin therapy is bleeding. Epistaxis, or nosebleeds, can be a sign of abnormal bleeding and should be reported to the provider for further evaluation and adjustment of the treatment plan if necessary.
Weight gain in (option A) is not a common adverse effect of heparin. Weight gain can be caused by various factors, but it is not directly related to heparin administration.
Bradycardia (slow heart rate) in (option B) is not a common adverse effect of heparin. Bradycardia can be caused by other factors unrelated to heparin therapy and should be evaluated separately.
Anorexia (loss of appetite) in (option D) is not typically associated with heparin therapy. Anorexia can have various causes, but it is not directly linked to heparin administration.
Therefore, the nurse should report the occurrence of epistaxis (option C) to the healthcare provider as a potential adverse effect of heparin therapy in the client.
Correct Answer is D
Explanation
Fidelity, also known as loyalty or faithfulness, refers to the nurse's commitment to keeping promises and fulfilling their responsibilities to the client. By promising to walk with the client in the outdoor courtyard each day, the nurse is demonstrating fidelity by maintaining their commitment to the client's well-being and providing the support needed to alleviate anxiety.
Autonomy refers to the client's right to make decisions about their own care and treatment. While the nurse's promise supports the client's autonomy by accommodating their preference for exercising in the courtyard, it is not the principle being demonstrated by the nurse.
Justice refers to fairness and equality in healthcare, ensuring equitable treatment and distribution of resources. While justice is an important ethical principle, it is not directly applicable in this situation.
Nonmaleficence is the principle of doing no harm and taking actions to prevent harm to the client. While the nurse's promise of walking with the client aligns with the goal of reducing anxiety, it is not specifically related to preventing harm.
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