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:
A boggy fundus 3 fingerbreadths above the umbilicus is not an expected finding after receiving oxytocin for excessive vaginal bleeding. This finding could indicate uterine atony, which is a concern, but it is not a typical immediate response to oxytocin.
Choice B rationale:
The client reporting uterine cramping is an expected finding after receiving oxytocin. Oxytocin is often administered to stimulate uterine contractions and reduce bleeding, so uterine cramping is a positive response to the medication.
Choice C rationale:
Saturation of perineal pad in 15 minutes is not an expected finding after receiving oxytocin. Excessive bleeding would be a concern, and the nurse should monitor for signs of hemorrhage.
Choice D rationale:
The client reporting burning with urination is not an expected finding related to oxytocin administration. This symptom could be indicative of a urinary tract infection or another issue unrelated to oxytocin. It should be assessed and addressed separately.
Correct Answer is A
Explanation
Choice A rationale:
The nurse's first action when caring for a client with bulimia nervosa should be to observe the client during and after meals. This is essential to monitor for signs of binge-eating followed by compensatory behaviors such as vomiting or the misuse of laxatives. Timely observation can help ensure the client's safety and provide an opportunity for immediate intervention if necessary.
Choice B rationale:
Suggesting that the client assist with meal planning can be a beneficial intervention, but it should not be the first action. Clients with bulimia nervosa often have complex emotional and psychological issues related to their eating habits, so it's crucial to address the immediate risks of binge-purge episodes before moving on to meal planning.
Choice C rationale:
Instructing the client about effective coping strategies is important for long-term recovery, but it should not be the first action. Immediate safety concerns, such as monitoring for binge-purge behaviors, take precedence in the initial care of a client with bulimia nervosa.
Choice D rationale:
Referring the client to a support group is a valuable intervention in the long-term management of bulimia nervosa, but it should not be the first action. The immediate priority is to assess and address any acute risks associated with the disorder, such as binge-purge episodes.
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