A patient is admitted to the mental health unit due to feelings of depression following a positive HIV diagnosis.
Which action should the nurse take to ensure a safe environment for this patient?

Replace paper trash bags with plastic biohazard bags.

Remove soft drink cans from the nurse’s desk and patient lounge.

Confiscate the patient’s cellular phone and provide a room telephone.

Ensure that prescribed medications are securely stored in the room.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Replacing paper trash bags with plastic biohazard bags is not typically necessary in a mental health unit unless there is a risk of exposure to blood or other potentially infectious materials. This action would not specifically address the safety needs of a patient with depression following a positive HIV diagnosis16.

Choice B rationale

Removing soft drink cans from the nurse’s desk and patient lounge is not typically necessary for ensuring a safe environment for a patient with depression following a positive HIV diagnosis. This action does not directly address the patient’s mental health needs16.

Choice C rationale

Confiscating the patient’s cellular phone and providing a room telephone is not typically necessary for ensuring a safe environment for a patient with depression following a positive HIV diagnosis. While some facilities may have policies regarding the use of personal electronic devices, this action does not directly address the patient’s mental health needs16.

Choice D rationale

Ensuring that prescribed medications are securely stored in the room is the correct action. This is a standard safety measure in healthcare settings to prevent medication errors and misuse. It is particularly important for patients with depression who may be at risk for self-harm16.

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Correct Answer is C

Explanation

Choice A rationale

Using the inhaler only when the patient is really short of breath is not an incorrect use of the inhaler. However, it might indicate that the patient is not managing their COPD effectively, as rescue inhalers like albuterol are meant to be used for quick relief of acute symptoms.

Choice B rationale

Having a hard time inhaling and holding the breath after squeezing the inhaler might suggest that the patient is not using the inhaler correctly. However, the patient’s statement that they “do their best” suggests that they are aware of the correct technique and are trying to follow it.

Choice C rationale

Swallowing after squeezing the inhaler is a clear indication of incorrect use. The medication from the inhaler is meant to be inhaled into the lungs, not swallowed. Swallowing the medication would lead to less of it reaching the lungs, reducing its effectiveness. The wave of nausea the patient experiences could be a side effect of swallowing the medication.

Choice D rationale

Shaking the inhaler several times before starting is actually part of the correct technique for using many types of inhalers.

A. The right foot is cool to the touch and appears pale and blanched. B. The pressure dressing at the right femoral area is moist and oozing blood. C. The client’s blood pressure trend is downward, and the pulse is rapid and irregular. D. The pulse distal to the femoral artery is weaker on the left foot than the right foot.

Correct Answer is A

Explanation

Choice A rationale

The right foot being cool to the touch and appearing pale and blanched is a classic sign of arterial obstruction. After a cardiac catheterization via the right femoral artery, it’s possible that a clot or other obstruction could have formed, impeding blood flow to the right foot. This would cause the foot to become cool and pale due to lack of warm, oxygenated blood.

Choice B rationale

While a moist and oozing pressure dressing at the right femoral area could indicate a problem such as bleeding from the catheter insertion site, it does not specifically indicate arterial obstruction.

Choice C rationale

A downward trend in blood pressure and a rapid, irregular pulse could indicate many different problems, including shock, heart failure, or arrhythmias. However, these symptoms are not specific to arterial obstruction.

Choice D rationale

A weaker pulse distal to the femoral artery on the left foot compared to the right foot could indicate a problem with circulation to the left foot, but it does not indicate an obstruction in the right femoral artery.

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A patient is admitted to the mental health unit due to feelings of depression following a positive HIV diagnosis.Which action should the nurse take to ensure a safe environment for this patient?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client is two hours postoperative from a cardiac catheterization via the right femoral artery.Which assessment finding indicates arterial obstruction?

Correct Answer is A

Explanation

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A patient is admitted to the mental health unit due to feelings of depression following a positive HIV diagnosis.
Which action should the nurse take to ensure a safe environment for this patient?