The nurse is assisting in the care of the client who is on the behavioral health unit.

Exhibits

Select words from the choices below to fill in each blank in the following sentence (Separate using commas).

The nurse should plan to
dropdown
and
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Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

The correct answer is choice A and E.

Choice A rationale:

The nurse should plan to ask the client what they are hearing. This is a therapeutic communication technique known as seeking clarification. It allows the nurse to gain more information and understand the client’s perspective. It can also help the client feel heard and validated, which can build trust and rapport.

Choice B rationale:

Telling the client their hallucinations are not real is not recommended. While it’s true that the hallucinations are not real, from the client’s perspective, they are very real and can be very frightening. Telling them otherwise can come across as dismissive and invalidating, which can damage the therapeutic relationship.

Choice C rationale:

Escorting the client to a group meeting may not be appropriate at this time. Given the client’s current state of agitation and confusion, they may not be able to participate effectively in a group setting. It could also potentially disrupt the group dynamic.

Choice D rationale:

Restraining the client should be a last resort and only used when the client is a danger to themselves or others. In this case, while the client is agitated and confused, they do not appear to be an immediate danger.

Choice E rationale:

Reducing excess stimulation around the client can be beneficial in this situation. Excess stimulation can exacerbate symptoms of psychosis such as hallucinations and agitation. By creating a calm and quiet environment, it can help reduce these symptoms and help the client feel more at ease.

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Correct Answer is A

Explanation

Choice A rationale:

Gentamicin is known to have ototoxic effects and can lead to hearing loss, especially when administered via IV infusion. Monitoring for hearing changes is crucial to prevent permanent damage.

Choice B rationale:

Slurred speech is not a common adverse effect of gentamicin. It is more associated with neurological issues or medications affecting the central nervous system.

Choice C rationale:

Hyperthermia is not a typical adverse effect of gentamicin. It may be a sign of infection or another underlying condition but is not directly related to the medication.

Choice D rationale:

Hypotension is not a common adverse effect of gentamicin. It is more commonly associated with medications that affect blood pressure or underlying medical conditions.

A. Monitor for muscle paralysis. B. Place in contact isolation. C. Check for increased salivation. D. Administer clindamycin hydrochloride.

Correct Answer is A

Explanation

Choice A rationale:

Monitoring for muscle paralysis is crucial in botulism poisoning because it is a characteristic symptom of the condition. Botulinum toxin causes muscle weakness and paralysis, which can lead to respiratory distress. Monitoring for these symptoms allows for timely intervention.

Choice B rationale:

Placing the client in contact isolation is not a priority in botulism poisoning. Botulism is not typically transmitted from person to person, so isolation is not necessary. The focus should be on monitoring and supportive care.

Choice C rationale:

Checking for increased salivation is important because excessive salivation is a symptom of botulism poisoning. However, monitoring for muscle paralysis is more critical as it can lead to respiratory compromise.

Choice D rationale:

Administering clindamycin hydrochloride is not a standard treatment for botulism poisoning. The primary treatment involves supportive care and, in some cases, the administration of antitoxin if available.

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The nurse is assisting in the care of the client who is on the behavioral health unit. Exhibits Select words from the choices below to fill in each blank in the following sentence (Separate using commas). The nurse should plan to dropdownand dropdown

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion.Which of the following manifestations should the nurse identify as an adverse effect of the treatment?

Correct Answer is A

Explanation

A nurse is assisting with the plan of care for a client who has botulism poisoning.Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

A nurse is contributing to the plan of care for a client who has leukemia and is experiencing chronic fatigue.Which of the following interventions should the nurse plan to include?

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A nurse is contributing to the plan of care for a client who is pregnant and reports having trouble sleeping.Which of the following instructions should the nurse include in the plan of care?

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A nurse is reinforcing teaching with the partner of a client who is receiving hospice care about music therapy for pain management.Which of the following statements by the partner indicates an understanding of the teaching?

A nurse is caring for a client in the prenatal clinic who has a possible ectopic pregnancy at 8 weeks of gestation.Which of the following findings should the nurse expect?

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A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnson syndrome.For which of the following manifestations should the nurse instruct the client to monitor and report?

The nurse is assisting in the care of the client who is on the behavioral health unit.

Exhibits

Select words from the choices below to fill in each blank in the following sentence (Separate using commas).

The nurse should plan to
dropdown
and
dropdown