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.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is A
Explanation
Choice A rationale:
Colostrum, the initial breast milk produced after childbirth, is crucial for a newborn's health because it contains a high concentration of antibodies, also known as immunoglobulins (IgA), which provide passive immunity to the baby. These antibodies are essential because a newborn's immune system is immature and not yet capable of producing its antibodies. IgA antibodies in colostrum help protect the baby against various infections, including respiratory and gastrointestinal illnesses. Therefore, choice A is the correct answer as it accurately reflects the importance of colostrum in providing immune protection for the newborn.
Choice B rationale:
Colostrum does not primarily provide vitamin K. While vitamin K is essential for newborns to prevent bleeding disorders, it is not the primary function of colostrum. Colostrum's primary role is to provide immune protection.
Choice C rationale:
Colostrum does contain trace amounts of iron, but its iron content is not the primary reason for its importance. Iron stores in a newborn's body are typically established during the third trimester of pregnancy, and colostrum is not a significant source of iron for the baby. The primary role of colostrum is to provide antibodies, not iron.
Choice D rationale:
Colostrum does not contain a natural diuretic. Its purpose is not to stimulate the newborn to void. Instead, it focuses on providing immune protection and essential nutrients for the baby's initial growth and development.
Correct Answer is B
Explanation
Choice A rationale:
The statement "Avoid breastfeeding for 3 days after receiving the vaccine" is not accurate. Breastfeeding can continue after the MMR vaccination without any adverse effects on the infant. There is no need to interrupt breastfeeding.
Choice B rationale:
The correct instruction is to "Avoid pregnancy for at least 28 days after receiving the vaccine." This is because the MMR vaccine is a live attenuated vaccine, and there is a theoretical risk of transmitting the virus to a developing fetus. Waiting for 28 days after vaccination allows the woman's immune system to respond to the vaccine and reduce any potential risk to the fetus. This is especially important during the postpartum period when a woman may be at risk of becoming pregnant again.
Choice C rationale:
The statement "If you are allergic to gluten, you should not receive this vaccine" is not accurate. The MMR vaccine does not contain gluten as an ingredient. Allergic reactions to the MMR vaccine are generally related to components of the vaccine itself, not gluten.
Choice D rationale:
The instruction to "Your partner should also receive the MMR vaccine" is not a standard recommendation for postpartum women. While it is essential for individuals to be up-to-date on their vaccinations, the focus in this scenario should be on the postpartum woman receiving the MMR vaccine to protect herself and any future pregnancies.
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