The nurse is assisting in the care of the client who is on the behavioral health unit.
Select words from the choices below to fill in each blank in the following sentence (Separate using commas).
The nurse should plan to
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The statement that "we require informed consent for all routine treatments" is not accurate. Informed consent is typically required for procedures and treatments that carry significant risks or require the patient's understanding and agreement. Routine treatments such as taking vital signs or administering routine medications do not typically require informed consent.
Choice B rationale:
The nurse should include in the teaching that the client can sign the informed consent form after the provider explains the pros and cons of the procedure. This statement emphasizes the importance of informed consent, which requires that the patient receives information about the procedure, risks, benefits, and alternatives before providing their consent.
Choice C rationale:
Stating that verbal consent is acceptable unless the surgical procedure is an emergency is not accurate. Informed consent generally requires written documentation, except in true emergencies when obtaining written consent is not possible due to the patient's condition.
Choice D rationale:
The statement that a family member must witness the client's signature on the informed consent form is not a universal requirement for informed consent. While witnesses may be necessary in some cases, it is not a standard requirement for all surgical procedures. The focus should be on ensuring that the client understands the information provided before consenting.
Correct Answer is B
Explanation
Choice A rationale:
The statement, "You will no longer be infectious once you have completed a course of antibiotics," is incorrect. Genital herpes is a viral infection caused by the herpes simplex virus (HSV) Antibiotics do not treat viral infections, including herpes. Antiviral medications are used for herpes management, but they do not cure the infection. The virus can remain dormant in the body and reactivate.
Choice B rationale:
"You should increase fluid intake to relieve dysuria" is a correct and important piece of advice. Dysuria (painful urination) can be a symptom of genital herpes. Increasing fluid intake helps dilute urine, reducing discomfort during urination.
Choice C rationale:
"You should have the lesions drained as they appear" is incorrect. Lesion drainage is not a standard treatment for genital herpes. Antiviral medications are typically prescribed to manage outbreaks and reduce their duration and severity.
Choice D rationale:
"You should wear nylon underwear until the lesions have healed" is not the recommended guidance. Wearing loose-fitting cotton underwear is generally advised for comfort and to minimize irritation during a herpes outbreak. Nylon underwear may cause friction and discomfort.
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