A very anxious client is hesitant to start a new medication and asks the nurse for guidance. The nurse responds, "I'm happy to review the side effects with you and discuss the pros and cons. This may help you make an informed decision, and I support you." In this scenario, the nurse is upholding the client's:

Autonomy

Beneficence

Fidelity

Veracity

Answer and Explanation

The Correct Answer is A

Choice A reason: The correct answer is a) because the nurse is supporting the client's right to make an informed decision about their treatment.

Choice B reason: Beneficence involves doing good and acting in the best interest of the client, but the focus here is on supporting the client's decision-making.

Choice C reason: Fidelity refers to being faithful and keeping promises, which is not the primary focus in this scenario.

Choice D reason: Veracity refers to truthfulness, but the primary focus here is on supporting the client's autonomy.

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Correct Answer is D

Explanation

Choice A reason: Providing a show of force is not therapeutic and does not align with the purpose of a therapeutic milieu.

Choice B reason: Fostering social relationships is important but is not the primary purpose.

Choice C reason: Synergizing with an autocratic leadership style is not the goal of a therapeutic milieu.

Choice D reason: The correct answer is d) because the primary purpose of managing the milieu on a psychiatric unit is to create an environment that supports clients in meeting their treatment goals.

A. Hypotension and venous pooling in the extremities. B. Pain and a burning sensation upon urination and hematuria. C. Profuse diaphoresis and severe, pounding headache. D. Reports of chest pain and shortness of breath.

Correct Answer is C

Explanation

Choice A reason: Hypotension and venous pooling in the extremities are not typical of autonomic dysreflexia. Autonomic dysreflexia usually results in hypertension due to an exaggerated autonomic response to a stimulus such as a full bladder. This condition is characterized by severe, uncontrolled hypertension rather than hypotension.

Choice B reason: While pain and a burning sensation upon urination and hematuria can be related to a urinary tract infection or bladder issue, they are not specific to autonomic dysreflexia. Autonomic dysreflexia presents with symptoms that result from the body's exaggerated response to the stimulus, such as severe headache and sweating.

Choice C reason: The correct answer is c) because profuse diaphoresis (sweating) and a severe, pounding headache are hallmark signs of autonomic dysreflexia. This condition occurs in individuals with spinal cord injuries at or above the T6 level and is triggered by stimuli like a full bladder, causing a dangerous rise in blood pressure and severe autonomic responses.

Choice D reason: Reports of chest pain and shortness of breath are not typical signs of autonomic dysreflexia. While these symptoms may be concerning, they are not the primary indicators of this specific condition. The severe headache and sweating are more indicative of autonomic dysreflexia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The psychiatric nurse works towards providing a therapeutic milieu for clients. What is the primary purpose of managing the milieu on a psychiatric unit?

Correct Answer is D

Explanation

A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?

Correct Answer is C

Explanation

A nurse is caring for a client who was admitted to the mental health unit for treatment. The client states, "I am a nurse on the medical-surgical unit, and I don't want my coworkers to know." Which of the following actions should the nurse take?

A nurse is administering oral sedative to a client who is receiving care following an involuntary admission. The client states, "I'm not taking any more medication." Which of the following actions should the nurse perform?

A nurse is preparing to administer 1500 mL of IV fluid to infuse over 2 hours. The nurse should set the IV pump to deliver how many mL/h?

A community mental health nurse is addressing substance use by adolescents. Which of the following interventions should the nurse include as a method of primary prevention?

A nurse is teaching a client who has a fear of heights about the use of systematic desensitization as a method of behavioral therapy. Which of the following client statements indicates an understanding of the teaching?

A client newly placed on an involuntary hold is being given an orientation to the psychiatric unit. The nurse includes information about the client's rights. Which of the following statements should the nurse include? Select all that apply.

A nurse performed these actions while caring for patients in an inpatient psychiatric unit. Which action violated patients' rights?