The nurse is assisting a coworker in preparing a patient for surgery. Which statement by the coworker should warrant intervention by the nurse?

"Will let the patient keep her nail polish on."

"Should remove her dentures."

"Can give her dentures to her family."

"Need a new set of vital signs before surgery."

Answer and Explanation

The Correct Answer is A

Choice A reason: Nail polish should generally be removed before surgery to allow the pulse oximeter to function properly, but it is not as critical as removing dentures.

Choice B reason: Dentures should be removed before surgery to prevent aspiration and other complications during anesthesia.

Choice C reason: Giving dentures to the family is appropriate after they have been removed, so this does not warrant intervention.

Choice D reason: It is standard procedure to get a new set of vital signs before surgery, so this statement is correct and does not warrant intervention.

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Correct Answer is ["B","C","D"]

Explanation

Choice A reason: Observing nonverbal communication is a valid nursing intervention for assessing a patient's anxiety level.

Choice B reason: Maximizing stimuli can overwhelm a patient with anxiety and is not a recommended intervention.

Choice C reason: Discouraging activities is not recommended as activities can be a form of therapy for anxiety disorders.

Choice D reason: Documenting only positive changes is not appropriate as all changes, positive or negative, should be documented for a comprehensive understanding of the patient's condition.

Choice E reason: Encouraging patients to verbalize thoughts and feelings is a therapeutic intervention that can help manage anxiety.

Choice F reason: Observing for signs of suicidal thoughts is crucial as anxiety disorders can increase the risk of suicide.

A. "You seem to be having some very frightening thoughts." B. "Why do you think you are being lied about and poisoned?" C. "You are mistaken. Nobody is lying about you or trying to poison you." D. "Who is lying about you and trying to poison you?"

Correct Answer is A

Explanation

Choice A reason: This response acknowledges the client's feelings without agreeing with the delusion or challenging their reality, which can help in building trust and rapport.

Choice B reason: Asking "Why do you think you are being lied about and poisoned?" could potentially reinforce the delusion and lead the client to further justify their beliefs.

Choice C reason: Directly telling the client they are mistaken can be confrontational and may damage the therapeutic relationship.

Choice D reason: Asking "Who is lying about you and trying to poison you?" can validate the delusion and is not a therapeutic response.

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The nurse is assisting a coworker in preparing a patient for surgery. Which statement by the coworker should warrant intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following are NOT nursing interventions for people with anxiety disorders? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

A nurse is caring for a client who has schizophrenia. The client states, "They lie about me all the time and are trying to poison my food." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A patient is receiving IV fluids at 100 mL per hour. Which assessment findings would indicate fluid volume excess? (Select all that apply.)

When setting limits with patients with personality disorders, the consequences of violating those limits should be set at which time?

Effective coping skills are described as:

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The sudden bursting open of the wound's edges is known as:

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